Deceased
Phoebe Handsjuk
Demographics
24y, female
Coroner
Coroner Peter White
Date of death
2010-12-02
Finding date
2014-12-10
Cause of death
Exsanguination from injuries sustained while attempting to climb from a height in the setting of alcohol and zolpidem consumption
AI-generated summary
Phoebe Handsjuk, a 24-year-old woman with a history of depression, anxiety, and alcohol abuse, was found deceased in the refuse room of her apartment building on 2 December 2010. The coroner found she entered a garbage chute on the 12th floor while in a zolpidem/alcohol-induced sleep-walking-like state or deeply confused state, without conscious awareness of the dangers. She sustained injuries descending approximately 30 metres through the chute, including catastrophic injury to her right leg from the compactor at the bottom. The coroner's analysis of her injuries, blood spatter patterns, and movement patterns indicated her descent was substantially controlled, not a free fall. The investigation initially focused on foul play but the coroner concluded this was neither suicide with intent nor homicide. Critical clinical lessons include: psychologists treating acutely suicidal patients should arrange crisis intervention plans and CAT team involvement; prescribers must counsel on zolpidem-alcohol contraindications; and emergency responders should prioritise life-saving assessment over scene preservation.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Court Reference: 2010 / 4605
FINDING INTO DEATH WITH INQUEST Form 37 Rule 60(L1) Section 67 of the Coroners Act 2008
Amended pursuant to 876 of the Coroners Act 2008 on 13 February 2015* Inquest into the Death of: PHOEBE HANDSJUK
Delivered On: 10 December 2014 Delivered At: Coroners Court of Victoria 65 Kavanagh Street Southbank Melbourne 3006 Hearing Dates: 5, 6,9, 12, 13, 14, 15, 16, 19, 20, 21; 22, 23, 28 August 2013,
8, 9 and 10 October 2013
Findings of: PETER WHITE, Coroner.
Representation: MRS. MOGLIA appeared on behalf of relatives of the Deceased.
MRR. GALBALLY appeared on behalf of Antony Hampel.
MR R. O'NEILL appeared on behalf of Chief Commissioner of Police.
Counsel Assisting the Coroner MS D. SIEMENSMA was present to assist the Coroner.
MS 8 GEBERT solicitor, to assist the Coroner.
Page I of 83
1, PETER WHITE, Coroner, having investigated the death of PHOEBE HANDSJUK
AND having held an inquest in relation to this death between 5 August 2013 and 10 October 2013, at Melbourne, find that the identity of the deceased was PHOEBE HANDSJUK
born on 9 May 1986, and the death occurred on 2 December 2010, at the Ground floor, Balencia Apartment Building, 454 St Kilda Road Melbourne, 3004
Tn the following circumstances:
On 2 December 2010, between 7.06 pm and 7.09 pm, Phoebe Handsjuk (Phoebe) born on 9 May 1986, was found (believed deceased), in the bin refuse room of the Balencia Apartments situated at 454 St Kilda Road, Melbourne.!
It is clear and it has not been a matter of dispute, that Phoebe entered the chute through the refuse entry point on the 12™ floor, which is the same floor of the apartment block where she had previously resided with her boyfriend, Antony Hampel (Antony).
It is known that Phoebe was alive at 11.50 am on 2 December 2010, when she was recorded on the apartment complex Closed Circuit Television (CCTV) returning through the lobby, (following a building fire alarm), where she can be seen speaking with members of the Metropolitan Fire Brigade. She is known to have then taken the lift to the 12" floor. A second
fire alarm sounded at 6.05 pm. It is unknown whether occupants left the building, at that time.
A computer analysis conducted by Mr Alexander Robinson, a Digital Forensic Analyst, Victoria Police E-Crime unit established that new IMac files were created at 12.01 and 12.02,
(Garage Band musicians).
There was also recorded activity again at 2.19 pm, which may have been automated, rather than as a result of human interaction with the computer. Later files were created at 6.19 pm, 7.01 pm, 7.39 pm and 7.40 pm. I note here that Antony is recorded by the door swipe technology as returning to the building and entering the building car park at 6.09 pm.
These materials, when considered together with all of the rest of the evidence, establish to my satisfaction that Phoebe must have entered the chute at a point in time between 12.03 pm, and a minimum of not less than seven minutes before 7.09 pm. I further note that Phoebe’s private Gmail account was still open when Antony returned to the apartment. Antony further testified that this occurred shortly after his arrival at the car park; (6.09 pm) and that on entry to the
' Scc transcript page 39. Nothing unusual had been seen or heard by Ms Ozulup or her manager Mr Giamarrio, who had been the only on duty staff that afternoon, Ms Ozulup ran back to her managers office to contact him as soon as she found Phoebe (believed deceased), in the refuse room. Her call was made at 7.1] pm. CCTV footage, which may have shown her hurried passage hack to the office, ceased at 7.06 pm. Allowing for the time necessarily taken to run back to the office and to make that call, I am satisfied that she first discovered the matier, al a point between 7,06 and 7.09 pm.
apartment he found that Phoebe was not there, and that he immediately commenced to seek to
find our where she was.
I also record here that a considerable amount of evidence has been presented touching on Phoebe and her ongoing struggle with mental illness, and alcohol and drug abuse, and in respect
of the ongoing difficulties, which arose in connection with her relationship with Antony.
Evidence has also been led concerning whether any person, Antony included, might have had access to Phoebe during the course of the day, and whether if so, such person may have caused
or contributed to her death.
The medical cause of death and the functional aspects of the chute and machine compactor have also becn examincd. At the request of the Handsjuk family, certain aspects of the police investigation have also been reviewed, with interested parties making various representations
about all of these issues.
Purpose of a Coronial Investigation
The purpose of a coronial investigation into a reportable death is to ascertain if possible, the identity of the deceased person, the cause of death and the circumstances in which the death occurred.” In the context of a coronial investigation, it is the medical cause of death, which is important (including the mode of death), together with the context or background and the
surrounding circumstances of death, which are proximate and causally relevant to the death.*
The broader purpose of a coronial investigation is to contribute to the reduction of the number of preventable deaths through the findings of the investigation and the making of
recommendations by coroners, a matter generally referred to as the prevention role.
Coroners are also empoweted to comment on any othcr matter connected with the death they have investigated including matters of public health, safety and the administration of justice; and to make recommendations to any Minister or public statutory authority on any matter connected with the death, including public health, or safety or the administration of justice. These arc
effectively the means by which the Courts prevention role may be advanced.
Detective Sergeant Butterworth of Purana Task Force on behalf of the Homicide squad was the initial investigator and he handed responsibility back to the Homicide Squad on the following
motning, December 3", through Homicide Senior Sergeant Shane O’Connell. Later the
? See Section 67(1) of the Coroners Act 2008.
? This is the effect of the authorities-see for example Harmsworth v The State Coroner (1989)VR 989; Clancy v West (Unreported, 17/08/1994, Supreme Court of Victoria, Harper J.)
Homicide squad, passed responsibility for the matter to the South Melbourne CIU, where
Detective/Leading Senior Constable Brian Payne, assumed the role of investigator/informant.
I further record that I have also received assistance since, from Detective Sergeant Solomon, who was requested by the Court to revicw the investigation, which he did with his report
becoming part of exhibit 42.
My finding draws on the totality of the material, the product of the coronial investigation into Phoehe’s death. This then includes the investigation and Inquest brief and the statements, reports
and testimony of those witnesses who testified at inquest and all of the documents tendered
through these witnesses.
All of this material, together with the inquest transcript, will remain on the coronial file.
In writing this finding, I further advise that I do not purport to have summarized all of the evidence, but have referred to it only in such detail as appears warranted by its forensic significance, and in the interests of narrative clarity.
Background
Antony Hampel*
18,
20,
e Background concerning Phoebe
In his first statement to police, Antony stated that he was born 1 August 1967, (aged 43 at the time of the events under consideration) and that he had met Phoebe during 2009, through an acquaintance. She was 23 at this timc. The couple began a friendship and saw each other over a period of approximately 6 months, following which Phoebe moved in with him at the Balencia Apartment Building. They had been together for approximately 20 months at the time of her death.
From the commencement of the relationship, Antony stated that he felt that Phoebe suffered
from, ‘depression, and struggled with drugs and alcohol’.®
She battled constantly with her illncss and was seeing a therapist as well as taking antidepressant medication. She changed doctors over the period of the relationship. At the time of
her passing, her GP was a Dr David Eisan and her psychologist was Joanna Young.
5 See second witness statement at exhibit 34(a) page 1.
§ See Antony’s first statement at exhibit 34 page 1. This statement was completed at 11.54 pm approximately 5 hours after he learnt of Phoebe’s death
21,
22,
25,
Again according to Antony, she was improving under her new therapist but,
‘she struggled every day to do the simplest things. Sometimes she could not go to work or da basic chores. When it got too much, she would drink and this is when T saw a complete personality change. She acted and spoke like someone I did not know at all and was very selfdestructive. She was angry irrational, agitated and felt she was worthless. Often this state would lead us to having an argument, or she would disappear for hours or sometimes a whole night and I would not know where she was. We always spoke about her struggle and ways to work on it together and she was in the most part committed to making herself better. I spoke with her family and found out that she had these problems for much of her life. They indicated
that they were at a loss as to what to da’.”
Phoebe loved to write and kept a diary. Her notes were often full of dark thoughts when she was in, ‘a bad place. Sometimes when she was drinking, she would cut herself, not seriously or
dangerously but more to draw blood and get a reaction.’*
Antony further stated that on the evening of Wednesday 1 December 2010, Phoebe had come home after having been gone over a period of two days. Her departure had followed an argument, which occurred during and after they had been out for an early dinner at the home of Julie and Mark Rockman, this on Monday 29 November 2010. When they got home Antony spoke to her about her alcohol intake and how it was a big problem. Antony went to bed and
Phoebe left the apartment soon afterwards.
Antony got up about an hour later and after discovering she had left, he tried calling her. She kept hanging up but during one such call, he could hear people in the background and Phoebe
told him she was with Brendan Hession, who was a friend of hers, and known to Antony.
According to Antony, she later went to her mother’s house arriving at around midnight on the Monday evening. ” She called him the following morning. After a brief conversation, she told him she was going to work but later a call was made from her workplace (to Antony), in which
he learnt that she had not been to work, and that her colleagues were calling to find out where
TTbid page 1 and 2.
I note that in later examination, Counsel representing Natalie Handsj uk, did not seek to dispute Antony’s evidence conceming Phaebe’s behavioural problems. See also Psychologist Joanna Young and Psychiatrist Dr Churven’s, analysis of this matter, set out below.
° The evidence of Russell Beard, the partner of her mother, tends to establish that Phoebe arrived at their home late in the evening on Monday November 29, 2010. See exhibit 42 page 149.
27,
29,
she was. ‘Throughout the day she rang and I rang her and I could hear that again she was
drinking and was wasted.’ !°
According to Antony, Phoebe returned to his apartment at around 9 pm that evening, (Tuesday 30 November 2010), and soon after got into bed and went to sleep. I note here that the door swipe technology establishes that Phoebe actually entered the Balencia, at 12.29 am on the Wednesday morning.
On the Wednesday Phoebe again stayed home from work.
Antony further stated (in his third statement, exhibit 34 (b) that he returned mid morning, after receiving a call from her grandmother, Jeanette Campbell, to check on her, and that it was at this
time that she told him that on the ‘'uesday she had been drinking and had taken ecstasy.
Antony then returned to work understanding that the cleaner, Shellie was in the apartment
during the day, and would spend some time with Phoebe during her stay.
Phoebe also told him that she had taken two sleeping pills following her return, and was
preparing to sleep on.
Antony took the remaining Stilnox with him when he left. Antony further testified that he was not aware as to whether Phoebe had taken Stilnox prior to December 2010. |! I also note here that he later stated in the transcript page 1399, ‘/ believe she would have taken them (Stilnox,)
before...but to my knowledge she wasn’t taking them on a regular basis,
At transcript page 1401, Antony further spoke of his belief that he had bought the StiInox back home with him on the Wednesday evening, and allowing for the toxicology report concerning
this matter, he believed that Phoebe must have again accessed this medication after that time.
Antony returned to the apartment after work on the Wednesday evening and found Phoebe still in bed. He cooked her dinner and she took a bath, took some vitamins and went back to bed, sleeping through the night. On the morning of Thursday 2 December 2010, Antony woke and left for work at around 8.30. Phoebe slept on and their dog, Yoshi, slept near by.
During the course of the day, Antony tried to call her. Her mobile was broken and he found
that he could not get through to her on the landline.
"° Ibid page 3. See discussion below, conceming Antony’s allegation thal Phoebe had misinterpreted what he said during the first phone conversation, and wrongly believed that he was telling her that the relationship was over,
1] Stinox was a sleeping pill used by Antony and made available to Phoebe, which Antony purchased for use to assist in sleeping when he travelled. Sec his second statement, exhibit 34(b) at page 4-5, and transcript page 1401.
According to Antony the Stilnox used on this occasion was obtained by him for their forthcoming trip to Paris, and was intended for use by them both. (Transcript page 1395-98) Sce also cxhibit 8, Phocbe’s report to her psychologist Ms Joanna Young, concerning her misuse of sleeping pills.
was open.
Antony was worried and hoped that she would walk in soon. He fed the dog and had a cigarette and a beer. He then ordered a take away. The deliveryman arrived and informed him that there were police in the downstairs foyer. He went downstairs and was told that a deceased person
had been found. | ‘My heart sank as I knew it was her.’
person was Phoebe.
‘I believe that as a result of Phoebe’s depression and alcohol abuse she took her life
tonight.’
death, Antony returned home, ‘and in the bedroom found a shrine on our bed’?
Antony went to the same GP and on one occasion had been present with Phoebe, when her
condition had been discussed.
and sometimes lent her money to buy clothes. They were meant to be heading overseas on
” See iid. (Statement to police of Antony Llampel dated December 2, 2010 at cxhibit 34).
'S Rxhibit 34(a) page 1.
According to Antony, the shrine included a photo of himself, a photo of her cat, and some small candles by the bedside table.
There were also some yellow postal notes given to police. Later cvidence at transcript page 1426 tends to establish that all items were located separately, on two bedside tables. Sec also exhibit 1 6(h) photos 100-4. T further note that photographs 1034 simply picture some posted notes and incense burner, with apparently used incense in situ, seen on one bedside table.
Personal photographs were located on the second side table, found on the opposite side of the bed, photographed at photograph 100.
holiday to Paris, on 21 December 2010, which according to Antony, Phoebe was very much
looking forward to.'*
On Wednesday night Phoebe called her father (from her bed), to wish him a happy birthday and to make arrangements concerning a birthday dinner. Dr Hansjuk mentioned that he hoped they
could meet for dinner the following night.
It appeared to Antony that during the conversation her father was lecturing Phoebe about her
drinking. Phoebe was exhausted and Antony suggested that they should speak further on the
following day.
Subsequently Antony learnt that Phoebe had spoken with her friend Vanessa Levin, (Vancssa) telling her that she, Phoebc, was upset with herself over yelling at Antony during their dinner at the Rockman home on the Monday night. According to Antony, Phoebe told Vanessa that she was thinking of jumping off the balcony. Vanessa, whom he believed was not familiar with Phoebe’s illness, told her that it would be OK and that couples often argued. Phoebe told
Vanessa that she wouldn’t leave.
In a third statement to Police, Antony was invited to provide further information concerning Phoebe’s phones. He offered that she had an iPhone and a Nokia phone, the latter of which she kept only because it stored all of her old numbers. She also told him that the Nokia contained numbers of contacts that she did not want to have in her life any more.'* Antony further stated that he took Phoebe’s iPhone for repair on either Wednesday but more probably, the Thursday morning. He recalled that this had happened after she told him it was not functioning, during a conversation in the bedroom on the Wednesday night, which occurred at or about the same time
that she phoned her father about his postponed birthday dinner. ‘6
Antony further offered that the swipe card system within the apartment building meant that it was impossible to get to his floor without the use of a properly designated swipe card. The only people who were in possession of such cards were Phoebe, Shellie the cleaner, and a Mr Kurt
Sari,'’ who rented a car space from him.
4 See exhibit 34(a) page 2.
‘5 Sce third statement at exhibit 34(b) page 1.
'S Antony maintained this version of events in the face of contradictory evidence concerning the repair of the phone, and the implication that the phone had becn used by him, (pretending to be Phoebe), to send an email to Phocbe’s family members at approx 10,30 am on Wednesday 2 December 2010. Subsequent evidence supported Antony’s position in regard to the timing of the iPhone repair,
'"T note Antony’s evidence concerning use of this card, as corroborated by the card swipe record, does not suggest that on 2 December 2010 Mr Sari’s card was used to access the buildings lift.
message from Phoebe stating:
“Hi Family. I’m in bed about to sleep. When I awake I will transform into the most incredible human being you've ever seen, not. I will go to hospital. It’s much safer there and I hear the special tonight is tomato soup. Delicious, nutritious. I love you all very much but not enough to send an individual text. Sorry but its time to sleep and I must be
on my way merrily, merrily, life is but a dream.” “
47, Antony felt that this meant that she was OK, but understood why some family members may
have seen it differently.
Jeanctte was concerned about the contents. Antony said he would go and check on her, and was adamant (in the face of an incorrect contrary allegation), that he did in fact go home to check on
Phoebe, during the mid morning.”
computer in question.”
® Relationship difficulty
Concerning the psychologists Joanna Young’s evidence, describing the relationship as
‘volatile’ ,...that this was true when she was drinking and that there were periods of instability.
It was very up and down ... we were very fond of each other ... we were trying to battle her illness as well... when she wasn’t drinking, which could be for weeks at a time, it
was very good,... great, but when she was drinking it would hecome very strained. ”
8 This was a message in fact sent to a number of her friends and family members on the Wednesday moming.
” Subsequent evidence from the building swipe log, exhibit 3(t), established that Antony had returned to his apartment during the day, on the Wednesday, but at 12.40 pm, rather than ‘mid morning’. At this time, his swipe card record showed that he entered through the front door and then into the lift to the 12th floor, and that he left the building 10 minutes later.
29 See exhibit 34(b) at page 5 4 Transcript page 1375.
Concerning suggestions that they had broken up 4 times in the last 6 weeks of her life, that this was broadly truc but that:
‘There was never a formal breakup we had 4 short separations, probably from October
up until December. *
And further that references in both her mother and father’s statement(s) and testimony, that Phoebe told (them) that he had thrown her out and that on one occasion that she was waiting outside on the footpath with her suitcase and a guitar, for her father to collect her, were also
broadly correct, but that in truth she was never,
‘thrown out, we were trying to work through the relationship, she never took all of her helongings. She would take a few things, she would be gone 2-3 days...this occurring
towards the last few weeks of her life.’ ”*
The last six weeks of her life included a week with her grand mother in Mallacoota; her father’s home for a few nights; one night at Vanessa Levin’s house and one night at the
Richmond home her mother shared with Russell Marriott.
Counsel assisting:
And that these all occurred because of the fact that you and Phoebe had disagreements.
De you agree with that?
Answer: ‘Yes’
Vanessa said that in the last six wecks of her life, Phoebe had discussed with her, ‘her
intention to leave the relationship’?
Answer: ‘We discussed,...we acknowledged there were problems. But we didn’t... she didn’t say to me the relationship was over, I’m leaving. No... And she didn’t say that she was thinking of leaving’.
That as relayed to Vanessa by Phoebe, in that last six weeks there was discussion during
which, she was encouraged by Antony to stay, which was, ‘a mutual decision’.
That as relayed to Vanessa by Phoebe, Phoebe may have interpreted his behaviour as, ‘controlling’, which opinion she had suggested to him directly, during periods when she was
drinking.?°
® Transcript page 1374.
® Ibid
™ Thid 1375-6.
e Exercise
That during their time together at the Balencia, Phoebe was very fit and would use the residents gymnasium two or three times per week depending upon her state, that she walked their dog, and rode a bike consistently, sometimes to work, that she also walked to and from
work, which was all part of her conscious effort to beat her illness.
That Brendan Hession’s evidence, that she liked climbing was correct, and that once, while in
Bali together, he saw her climb a tree, (she), ‘must have been 15 feet of the ground, ...’* |
T also saw her at a function once when she was quite drunk, climbing on to a rooftop
outside the apartment where the function was.’ ””
Phoebe’s finances were in a poor state. She worked as a receptionist, 3 days a week in an advertising agency, owned by Michelle Scvona. Betweon October and December 2010, her attendance at work had been very inconsistent, sometimes not attending for days at a time. On average, she didn’t attend on 1 day in 5. Phoebe did not pay rent (earlier sct at $150 per week), when she wasn’t working, ‘when she could afford it, she would contribute, there was no
formal rental agreement’.
Counsel Assisting:
So if she didn’t pay one week you wouldn’t go after her and say you owe me ‘x’ amount
of money ?...
Answer:.No response.
Antony was not aware of what happened to her income on the occasions she did not go to work. He was aware that she had had difficulty meeting some expenses and was being assisted
by both her grandmother and her father. He was also aware of a text set out at the bottom of
page 34, (message 67) where he wrote to her, |
5 Thid 1377.
6 Sc statement of Brendon Hession at exhibit 42 page 162 and his oral evidence at transcript page 498% where he testified about incidents he witnessed, in which Phoebe had climbed a fire escape, and building wall(s). He couldn’t say if this was undertaken as a challenge or not.
Q ‘But you remember that her interest in climbing and physical activity might play out in ways that you wouldn’t normally have predicted?
A Yes that’s right.’ 7” See transcript page 1378.
Page Ll of 83
‘Also don’t forget you have bills to pay me and I’m not loaning you any more money, so
be sure to go to work’.
Antony further stated that:
‘She struggled generally because she didn’t earn a lot... T am not sure that it weighed on her mind in the sense that if worst came to worst and for whatever reason she couldn’t get support from her family, T would not have thought twice about paying for it (consultations with the psychologist),
No-1 don’t think it weighed heavily on her mind... no.”?
e Alcohol intake
Antony further offered that she was very sensitive to two glasses of wine, which could be
enough to see her personality shift. He described her as a,
‘binge drinker, who might go for up to three weeks without a drink. Her drinking to excess on sequential days was unusual. ...1t would vary but it was never a large amount.
No evidence of clumsiness, dropping things or stumbling...there was however, a personality shift, the way she would speak her general nature would shift. She would go from being quite reserved, (but she was also quite outgoing), through to a point where there was more laughter more giggling and from there to a point where her aggression
and anger increased, (the more she drank).
And, it would become more difficult to connect with her and conversation would become more difficult. She acknowledged that she had a problem. She would not distinguish her depression, from her drinking. She saw it as all part of the same problem.
Antony noticed that from September through to December the effects of her alcohol use were
becoming more severe, and that she was becoming more erratic in her behaviour.” © Mlicit drug use Counsel assisting:
‘Miss Levin also said that Phoebe told her that when she just took drugs she wouldn't get depressed, but if she combined the drugs with the alcohol then she would suffer from
symptoms of depression, was that something that you had observed’?
?4 See transcript page 1383 and exhibit text messages at exhibit 34(c). See also later evidence of psychologist Joanna Young, ® Transcript page 1380-81.
"Ibid page 1393.
Answer: ‘Not that I observed no... I could assume that because many of the times she would be out drinking and in that state I wasn't with her, so I don’t know what she would have been doing in that time...She told me on several occasions she’d taken a lot
of drugs before, yes.’
Court:
‘She never did it in your apartment’?
Answer: ‘Not to my knowledge. I could only go on what she told me she had taken”! 5
As noted above, when he returned to check up on her following Jeanette Campbell’s call on the morning of Wednesday 1 December, she told him she had used ecstasy while out over the
previous day, a fact confirmed by Ben Silver.*?
Prescribed medication use
Antony was not aware of Phoebe’s use of Iexapro, or that her prescribed dosage of the antidepressant medication, (“Cymbalta”) had been increased from 30 mg to 60 mg, on the 13 September, 2010.
He was aware that she had taken Stilnox (10 mg) previously, but had been surprised to learn that she had reported to her Doctor, taking 5 sleeping tablets from his supply, over 5 days in
August.” The sleeping medication, Immovane, prescribed to Antony, was also available to
Phoebe.™ See also paragraphs 30-32 above, reference her usc of Stilnox.
Occasional disappearances
Reference Phoebe’s occasional disappearances, prior to the last wcek Phoebe had disappeared overnight on two occasions in 2010 without saying where she was going (or had been), The
two nights in a row, during the last week, was unusual.
! Transcript pages 1385-86. T note here that on Tuesday November 2010, two days before her death, Phocbe met with Ben Silver and is reported to have discussed with him her plans to get off, ‘cocaine and speed.’ Sce exhibit 42 page 157.
Lexapro and Cymbulta are both anti depressant medications used in the treatment of a major depressive disorders and general anxicty disorders.
See also Antony’s observations concerning Phoebe’s allegedly erratic behaviour from September 2016, offered in conjunction with f/n 30 above, and the further discussion concerning her usc of Stilnox, as sct out above in conjunction with f/n 11, See also the evidence of Ms Young concerning Phocbe’s reporting of her misuse of sleeping pills, at exhibit 8.
Sce transcript page 1399
© Suicidal Ideation In reference to suicidal thoughts, Antony testified that Phoebe had never directly spoken to him about suicide, but they had oftcn talked about her struggle.
‘Everyday was a struggle for her...so I guess it could well be something she was
thinking’.
Antony believed all the right steps were taken to assist Phocbe. She was seeing a psychologist,
she was taking antidepressants and when, ‘she wasn’t drinking she wouldn't touch alcohol’.
She would eat well and drink tea.
Antony was additionally questioned by Counsel Assisting, in connection with the Rockman dinner, and the argument on Monday 29 November, and Vanessa J.evin’s evidence that Phoebe had complained about his behaviour over dinner, this occurring when she had tried to
speak to Julie Rockman, about her difficultics.
Antony’s recollection was that their discussion had centred upon her drinking, and what to do next, and possibilities he had earlier discussed with her grand mother, Jeanette Campbell, Any discussion (with Phoebe) about her drinking, ‘would result in a very aggressive response’.
On the Tuesday morning, Phoebe sent a message to Vanessa Levin at 8.33 am, stating that, ‘7
left home last night again and I am lost’. 46
A similar message was sent soon after, to her brother Tom.
Antony further recalled that they had a disagreement over the phone on the Tuesday morning, before her message went out. He offered that he believed that she had misinterpreted his words as meaning he thought it was over, rather that they had to find a way to work it out. Antony also recalled sending a message, possibly from her iPhone, to Brendon Ilession, (this on
Tuesday evening 30 November), seeking information as to her whereabouts.
On the Wednesday morning, the building swipe records suggest that Phoebe entercd the apartment building at 12.29 am. Antony accepted this time as accurate and testified that when she got in, she was quite drunk and had the hiccups, and that she got straight into bed and
® Transcript page 1387, 6 See exhibit 3(t)
didn’t say anything, and nor did he.*’ Antony left the building to go to work at 8.11 am and
returned at 12.40 pm at the request of Jeanette, to see how Phoebe was getting on.
Antony found Phoebe asleep in bed at this time and woke her. By this point Antony felt that
Phoebe was in a cycle and coming out of it. She was flat but coherent.
As set out above, Phocbe spoke about her slecping pill intake and Antony took the bottle
containing the Stilnox, away from the apartment when he left.
She also told him that on the Tuesday she had taken ecstasy, while at an address in South Melboume. Antony did not believe that this would have occurred in connection with her meeting with Ben Silver, whom he knew. He also was not aware that Phoebe had rung
psychologist Joanna Young, to seek her help on the Tuesday.
When he returned to the apartment on Wednesday evening, Antony found her in what he
described as, ‘recovery mode’.
She wanted to eat, she wasn’t very conversational, She was still hung over. ‘... it was also always the beginning of beating herself-punishing herself, beating herself up, not in a physical sense but in a mental sense... it was a real kind of self-loathing... [ think she was really
starting to struggle to think how she was going to stop this cycle from happening. ad
Antony further recalled showing her the tickets for Paris on the Wednesday night, as a means
of trying to encourage her and to install some hope and confidence.
‘She was very excited’.
Antony further testified that Phoebe never expressed concern to him about the trip and or the possibility that he would propose to her while they were abroad, or the possibility that she would be abandoned without funds, both of which concerns, she had earlier discussed with
Vanessa Levin." Thursday 2 December 2010
The building swipe records show that Antony accessed the building gym at 8.13 am on Thursday 2 December 2010, and that he left to go to work at 9.01 am and returned through the garage door entry at 6.06 pm. His further testimony was that he didn’t lend his card to any one
77 Sce transcript at page 1411,
58 See transcript at 1411-13 and relevant building swipe records at exhibit 3(t).
» Sce transcript page 1416,
" Ibid
during the course of the day.” He then gave a full account of various business related activities undertaken on that day, most of which included interaction with various associates
and members of staff.°
was locked or not at that time.
54, In the kitchen, he found a glass, from which he assumed she had been drinking, which smelt
of vodka."
He was keen to look for any clue as to where Phoebe was and what was happening.” He also
opened his own cmail program, Entourage.
spoke for 3 and 2 minutes.
” Transcript page 1423 records that the witness gave an inaudible response when asked about lending his building entry card on 2 December 2010. J am satisfied that in fact the witness denied this suggestion.
“’ T note here that several of the persons similarly involved in these events, later corroborated Antony’s account of his movements after he left home on the morning of 2 December 2010.
“ As Phoebe had left her phone, handbag and keys in the apartment, this question was initially addressed to the witness in writing to scck to add to the information concerning Phoebe’s own state of mind, at the time that she left the apartment.
*S See fin 10. See also exhibit 16(h) photos 100-4. It is appropriate to note here that photographs 103-4 simply picture some posted notes and an incense burner, with apparently used incense in situ. Personal photographs are to be seen on the second side table, found on the opposite side of the bed, and photographed at photograph 100, See also transcript page 1473 where it is suggested that the photographs Antony was referring to may have been left on the bed.
“6 See exhibit 16(h), photo 121.
*” Antony testified that they used the same password to open the computer but had separate email addresses with separate passwords to enter, to access thosc addresses. As to the blood found on the computer mouse see exhibit 16(h) at photo 86.
6l.
He was therefore not aware of the 6.51 pm call from Dr Handsjuk and believed that tt was just a coincidence that he had called him so soon after Dr Handsjuk had attempted to spcak to Phoebe on her iPhone, (which Antony believed was in the repair shop at that time).” The phone in question was later recovered from the repairer by Antony’s father, on 7 December,
and given to police the same day.
Under further examination from Counsel Assisting, Antony stated that he believed that it was possible he may have accessed messages sent to Phoebe, before the phone was handed to
police, but that he had no recollection of doing so.
Antony did not dispute that messages sent to Phoebe’s iPhone by Vanessa Levin at 1.57 pm 2 December 2010, Sara Bruce at 4.31 pm 2 December 2010, and Jeanette Campbell at 8.16 pm, to Phoebe, had in fact been read.*° He also testified that he owned the iPhone telephone account and following the return of the phone and phones’ sim card from Victoria Police that
it had been re-issued in uncertain circumstances, and could not now be located,”!
At 8.03 pm on the ‘lhursday, he had buzzed in the delivery man, and that soon after he discovered that Phoche was deceased. He informed Dr Handsjuk, and later records indicate
that Natalie Handsjulk called the apartment number on the landline.
Under further questioning Antony offered that the bag found in the waist bin on the ground floor near where it is believed that Phoebe also fell, was similar to the type of bag he believed they were using at that time.’ He also testified that he had never been into the buildings
ground floor refuse room, Counsel Assisting:
‘Can you tell his honour whether you had any involvement in the death of Phoebe
Handsjuk?
Answer: ‘Absolutely not.’ Counsel for Antony Hampel.
Counsel for Antony Hampel then questioned his client. At the time, Phoebe moved in to the
apartment in October 2009, he knew that she had been treated for depression and alcohol
% Sec transcript page 1446,
» See transcript page 1465 and photograph exhibit 16(h) at 39.
Page l7of83
69,
70,
abuse. From that time up until 2 December 2010, he never asked her to leave, nor did he ever
either verbally or physically abuse her.
Antony further testified that they never formally separated, but there were three or four occasions, when she left for up to 3 nights, all of which occurred after October 2010, During
their time together, the only time they argued was about her drinking.* The last week of her life was the worst he had seen her, ‘and it was certainly a trying time.’
Antony was also again asked about the iPhone and (again) testified that he was told by Phoebe it wasn’t working and dropped it in for repair the following morning, 2 December 2010 , and that he hadn’t called her on that number after that time, attempting to contact her
instead using the apartment landline and her old Nokia line.**
Antony further stated that to the best of his knowledge, Phoebe never used Stilnox prescribed to him.”
Counsel for the Handsjuk family.*
Antony agrecd with Counsel that the relationship was difficult. He also agreed that a comment he made to her in late November, may have been mistakenly thought to mean that he was ending the relationship. He also accepted that her misinterpretation may have led her on 23 November, to inform her father that she had been thrown out.
Antony had previously spoken on a number of occasions with both her mother Natalie Handsjuk, and grandmother Jeanette Campbell, about Phoebe’s medical history and her difficulties. One such conversation took place with Natalie, who was in Western Australia at
the time, this about one week prior to Phoebe’s death.
In situations when they were out together and a drink was offered, she would usually have a plan about how much she would permit herself: Antony would ‘go with’ the plan but often noted that she would just try and avoid such situations and relevant people, altogether.*’ However, there were a number of engagements, which they did attend where she would begin
by having a couple of drinks, but found that she could not then control her intake.
See transcript page 1468-69.
See transcript page 1470.
See discussion at transcript page 1472, in respect of his taking the Stillnox bottle to work, after his return to check on Phoebe early on the Wednesday afternoon. See also footnote 11, above.
*8 Counsel represented both Natalic Handsjuk and her father Lorne Campbell, in respect of this examination. See the Courts discussion with Counsel establishing the above, at transcript page 1506.
*’ Transcript page 1478-79
73,
75,
77,
According to Antony the Rockman dinner was a case in point, with Antony agreeing that he had messaged Phoebe on a couple of occasions about the importance to him that she attend
this dinner.~®
Message 18 described Phoebe’s response, which was that she really was not well and feeling
poorly, and how it caused him to cancel the first appointment with the Rockman’s.
Antony additionally responded to her concerns, by cancelling another dinner at the Balencia with the Rockman’s set for the Thursday, and by cancelling a trip to Nagambie, the next weekend, (although he was aware that Phocbe had looked forward to the trip as she loved
being in the country and away from the city).
In later messaging Antony agreed that he had spoken of their Paris trip and that he had included, T hope you will still be my partner for this adventure,’ which he agreed was
indicative of the difficult previous 24 hours, between them.”
Antony further stated that he was not present on Monday 29 November 2010, when she talked over the phone from the balcony, or that he had heard her speak of committing suicide then or earlier, but that he was now aware that Vanessa Levin had said that Phoebe had spoken to her
about suicide, three to six months earlier.
Antony agreed with Counsel that he had tried to phone her 27 times during her absence in the one-hour period from 11.30 pm Monday night, until 12.30 am the next morning, He was,
‘desperate and very worried’,
Further after leaving for work on Wednesday 1 December 2010, (she was still asleep), he rang
the home line, which she did not answer. He was not able to get through to her at all that day.
On the Wednesday night she was not talking a lot, but there was no friction between them.
His impression was that by the Thursday morning she was coming out of her cycle and
getting better.
Antony recalled their dog Yoshi, greeting him when he came home from work on the
Thursday night. He thought the incense in their room had been recently burning.
58 This was to be the first time that she had met the Rockman’s and the dinner had earlier had to be rescheduled, duc to her ‘ill health. ‘Transcript page 1480 and messaging at exhibit 28(c), message no 32 and 33. Part of the purpose of the meeting was to introduce the Rockman’s and their children to Yoshi, to see if the family felt comfortable with getting a dog of their own.
» See transcript page 1483.
He agreed that his iMac computer had him listed as the organiser for a number of upcoming
events.” He also knew of a Matt Flynn, who was a colleague, who had called him while he
waited for Phocbe that evening.
He also confirmed that he had thought there might be something relevant to her whereabouts
on their then open computer, when he returned to the apartment.
Antony further stated that at some point he informed the police that, hc had searched the computer with the intent of finding anything relevant that Phoebe may have recorded. He confirmed that a copy of the computer hard drive was currently (August 23, 2013), with
VicPol, for the purposes of analysis.
Counsel for the Commissioner for Police.
Antony further testified in answer to a question from Counsel for the Commissioner for Police, that to his knowledge Phoebe used two email addresses, one the Gmail address and one
a work address, and that both were used by her, for social purposes.
Court.
In response to questions from the Court, Antony stated that some of the functions Phoebe and he attended together, were related to his work as an cvents organiser. She did not go to all such events in part because she did not want to, and in part because he felt that her attendance was
not required. She always found social events other than those related to family, quite difficult.
In response to a question connecting her financial difficulties to whether she had a concern about how she could re-establish herself, (if she chose to terminate the relationship), Antony felt that she was always independent, but did face difficulty because of her inability to worl full time.
She was never forced to come back to him. She only ever returned after discussions they had
about trying to find ways to move forward.
While she wasn’t directly involved in his business life, she had enjoyed attending certain
events.
Inserting a date reminder in a meeting schedule programme will often have the event organiser listed as the author of the
reminder.
5! See transcript page 507.
~~ Page 20 of 83
Natalie Handsjuk (Natalie)
90, 91,
92,
93,
95,
Background concerning Phoebe
Natalic resides in Richmond with her partner Russell Marriot, who is a chef. Natalie last saw Phoebe on September 28 2010, when she had dinner with her, her two sons ‘om and Nickolai, and her partner Russell, this prior to leaving the following day on a 9 week working
trip to Western Australia.
This was a family night and they did not talk about Phoebe’s relationship with Antony.
Phoebe and Antony had been together for approximately two ycars.
Prior to moving in with him, she had been living with Natalie. Natalie felt that she and Phoebe had a close relationship. At this time, Phoebe was seeing psychiatrist, Dr Peter
Churven.©
Natalie further stated, confirming the version offered by Antony, that Phoebe had separated
(or taken time out) from Antony, on 4 occasions in the six weeks before her death.
Natalie also recalled an carlicr incident of instability in their relationship and detailed her
knowledge of an argument, which occurred between them over the phone, while Antony was
_in Paris and Phoebe in her home. ‘The next day Phoebe woke and was very distressed about her
behaviour the previous night. Later she conferred with both Dr Peter Churven, her own psychiatrist, and her father, Dr Leonard Handsjuk, a psychiatrist. Hospitalisation was discussed, but finally it was decided that Phocbe would go and stay with her father.
Natalie further detailed how Phoebe had begun using illicit drugs, (speed, ecstasy, marijuana) and alcohol from the age of 14 years.
She also detailed a time when at 15 years of age, Phoebe had run away from home and stayed away for a period of 8 weeks. She had left school by this time and Phoebe later told her mother that during this period, she had lived with an unknown male, his partner and her new baby. The male had just been released from prison. Phocbe later left and returned home
following an incident of domestic violence, in that household.
Natalie stated that she believed that Dr Churven had later prescribed Phoebe valium, ‘to help
her abstain from drinking’.
® Natalie Handsjuk provided 2 statements to the court concemming Phoebe, (her daughter with Leonard Handsjuk), and Phocbo’s background.
At the time of the making her statements she was self employcd as a candle maker and arts worker,
® Dr Peter Churven provided a statement, which is referred to below and became part of exhibit 42, at page 218.
~~ Page 21 of 83
99,
The days leading up to and events of 2 December 2010.
Natalie arrived back in Melbourne on Wednesday, 1 December 2010. At around 11 am while waiting to board a plane back to Melbourne, she had received Phocbe’s text to her family members, discussed above in conjunction with Antony’s evidence.®! Natalie rang her mother straight away and indicated her conccrn. She asked her to ring Antony and we know from the
evidence of both Antony and Jeanette that this in fact occurred.
After Natalie arrived back in Melbourne, she had a text message from Antony reassuring her
that all was well.
On Thursday 2 December 2010, Natalie got up early to help prepare a party for her son Nickolai, (Nick) whose 18" birthday was to be celebrated at her home the following evening.
She had not heard from Phoebe but was pre-occupied with the party and did not pay particular.
attention to her failure to call.
At around 7 pm, Phoebe’s fathcr Leonard called and said Antony had returned to the apartment and that Phoebe was missing having left her keys and her bag in the apartment,
which Natalie found alarming as it was so unusual.
Her first thought was to call Phoebe’s friend Brendan Hession, whom she often turned to, when she was upset. She rang Brendan and was informed that he had not seen her since the Monday night.
Soon afterwards, Natalie returned earlier missed calls from Leonard and was informed that
Phoebe had died and had been found near the garbage bins at the apartment.”
Jeanette Campbell (Jeanette)
Background concerning Phoebe
Jeanette was Phoebe’s maternal grandmother and lives at Mallacoota, south cast NSW.
Jeanette (and others) felt that she was probably the relative who was closest to Phoebe. Right through until the time of her death they spoke on the phone on average, three or four times per
week,
When Phoebe was 14, she lived at home with her parents Natalie and Lenard. Jeanette lived in a studio above their garage. Phoebe at this age was described as, quite hormonal, romantic,
intuitive and very sensitive,
Set out in full at page 9 above.
® Ibid page 82.
She started drinking alcohol at this time and her grandmother felt that her mood swings were considerable. The general fecling in the family was to leave her alone when she was in one of, ‘her moods’. When she was 15, Jeanette became aware that Phoebe was using drugs. Jeanette warned her about the dangers of this conduct. Jeanette and Phocbe frequently discussed
Phocbe’s romantic life.
Jeanette also observed that Phoebe was physically strong and loved any physical challenge,
rock climbing, bushwalking, netball, camping and hiking.
By the time Phoebe was 18, Jeanette was living in Mallacoota and Phoebe in Melbourne. In their phone conversations, Phoebe would often report suffering from a hangover. When
Phoebe drank, she would become verbally aggressive and, ‘smart mouthed’.
Jeanette became aware of Phoebe’s new relationship with Antony in 2009. They seemed to
get along well but Jeanette was concerned about the difference in their ages.
At about this time Jeanette spoke to Phoebe about a cut on her arm. Phoebe admitted that she had done it deliberately, but stated that she was not suicidal. They agreed that Phocbe would.
contact her grandmother, at any time of day or night, if she ever had similar thoughts again.
Jeanette was aware that Phoebe had been prescribed medication for depression on a regular basis, but that she would stop taking such medication as soon as she felt well. Jeanette cautioned Phoebe about this matter and also about the dangers of drinking while she was on
medication.
Icanette further observed that the relationship between Antony and Phoebe was often turbulent and that he was jealous over her male fricnds, or friends from work, as well as
fricnds in her past, She left him at least a, dozen times during their relationship.
Phoebe came to Mallacoota and stayed with her between October 21 and 24, 2010, this following a decision to leave Antony. Phoebe told her that Antony wanted to take her to Paris
and that the relationship was not working and that she was very unhappy.
‘Tt doesn’t matter what or how much Ido. 1 can never get it right. I am sick of it.’ Following phone calls from Antony, Phoebe left Mallacoota and returned to Antony.
I note here that while in Mallacoota, Phoebe had been offered a job working at a local golf
club, a position she had previously held and apparently enjoyed. It is also relevant that on the
5 Thid page 181.
evening of Monday 29 November 2010, she spoke to Brendon Hession about plans to return to
Mallacoota.*”
On Tuesday 30 November 2010, Jeanette received a message from Antony saying Phoebe was missing and seeking any information she may have. Later that afternoon she received a
message from Phoebe saying shc was OK and would call tomorrow.
The next day she received the text from Phoebc, which was the same message sent to other family members, as discussed above. This, ‘freaked her out’, and she spoke with both Natalie and Antony who later texted back saying only that Phocbe was sleeping peacefully and that,
‘Now was the time to heal, then when she feels OK we will work out a plan’.
On the night of 2 December 2010, Jeanette, who was in Melbourne, was called to Natalic and
Russell’s home and informed of her granddaughter’s death.
Russell Marriot: (Russell)
Background concerning Phoebe
Russell viewed Phoebe as someone who needed to be treated with some care. She wasn’t confrontational, but she was very strong.
‘[ don’t think there was anyone who was close to Phoebe who did not have a spat with
her, and we had a couple.’ 70
Russell recalled a visit from Phoebe late in October 2010. According to Phoebe, Antony had again cut himself off from her, after she had been drinking. The drinking was a major difficulty for Phoebe, which turned her into a different person, while Antony, ‘would just lock him self away’. She left shortly after the conversation and according to Russell’s
understanding, she returned to Antony.
Russell again also saw Phoebe on her way to her grandmother in Mallacoota. This occurred some 3 weeks before her death and according to Jeanette, Phoebe’s stated at this time her
intention was to leave Antony.
© See statement of Brendan Llession exhibit 9 at page 2, and transcript at page 485. As to her employment opportunity see the evidence of Keith Allan.
® Thid page 182-3.
® Russell Marriot was the partner of Natalie Llandsjuk, and had known Phoebe for three years at the time of her death.
” See exhibit 42 page 149.
122,
123,
124,
126,
129,
She was however persuaded to return to Melbourne, to try and work things out and this she did despite having found herself with a job offer, (in familiar and previously satisfying
employment), if she stayed on or chose to return to Mallacoota at a later point in time.”!
After her return to Melbourne, she rang Russell and said that she and Antony were trying to work things out.
On Monday 29 November 2010, following the Rockman dinner Phoebe called and described the altercation, which had occurred. Russell was worried about her state of mind and phoned Natalie in Alice Springs. Later at around 12.30 to 12.45 am, Phoebe arrived unexpectedly at his home. She was drunk but, ‘not incoherent’.
Russell thought that her presentation at the time suggested that she may have taken, speed.
She was functioning well however and wanted to go out. She said Brendon Hession was waiting for her nearby. They talked for ‘hours’ and at approximately 3 am, Russell made up a bed for her.
‘She told me that she loved Antony to bits but still wanted to leave him. She wanted to
leave him because of the way he behaved when she was not on top of her game.’
Russell got up at 7 am the next morning and went to wake Phoebe, who said that she was getting up to go to work. He told her that she was welcome to return after work and stay there,
if she wanted to do so.
Phoebe left and later that day Antony texted him about her whereabouts.
On the Wednesday Russell received the family email referred to above. He considered that this
was Phoebe ‘venting’, and he was concerned for her wellbeing.” Thursday 2 December 2010
On the evening of the following day 2 December 2010, Russell was with Natalie, (who had arrived back from Alice Springs), when they learnt from Leonard, of Phoebe’s death.
During the course of this day, Russell and Natalie had commenced preparing for Nick’s 1g
birthday, which had been planned for the following evening.”
™ See evidence of Keith Allan, concerning Phoebe’s employment opportunity in Mallacoota.
® Tbid page 152.
® Transcript page 291.
™ Nick was born on November 16, 1992. | assume that the celebration of his birthday was delayed to allow for the return of his mother, (Natalic Handsjuk).
In response to further questioning by the Court, Russell testified that Phoebe was proactive in
trying to be better. She was always striving to recover.
In the week prior to her death, Phoebe had discussed with Russell, plans for her brothers party on the Friday, to be held in the back yard at their Richmond home. This was a major
family event with everyone putting in an effort.
‘And she was up and about and laughing and chirpy’.
She was coming back the day before the party and we were preparing for the party. She was
to, ‘lend her eye,’ to the decorations.
Russell further advised of his view that Phoebe and Nick were very close and that he (firmly) believed that she would not have committed suicide on the eve of such an important family
event.”
Tn additional testimony, in response to a question from Counsel for Natalie Handsjuk, Russcll
offered that Phocbe could be a bit clumsy when she had been drinking.
Dr Peter Churven’*
135,
Dr Peter Churven was Phoebe’s psychiatrist between June 2008 and December 10, 2009 and saw her on 15 occasions. In a report dated 9 February 2011, he stated that:
‘Phoebe presented as an intelligent likeable, attractive young woman. I considered her
to have the following issues.
Axis 1 - Adjustment Disorder with depression of moderate to severe degree.
This disorder was manifest since the age of 13 to 14 yeurs, when she went on a drinking binge with peers in school hours. ‘At 15, she ran away from home and after that her parents, could not control her. Phoebe described periods of depression and self-loathing, often following
drinking binges during which she was vulnerable to compromising relationships.
Substance abuse (moderate) Alcohol abuse (305.00) Phoebe had been binge drinking since 14 or 15. At the time of seeing me initially, she had been sober for 7 days, after a binge on
vodka. She described at various times using/abusing pot, ecstasy and other drugs.
Axis 2
See transcript page 298, When asked if Phoebe and Nicolai were very close, Russell answered in the affirmative. In answering this question he spoke with emotion and his response on this occasion, was not successfully recorded by the transcription service.
Dr Peter Churven was Phoehe’s psychiatrist between June 2008 and December 10, 2009 and she saw him on a total of 15 occasions, See his report at exhibit 42 page 218.
Phoebe’s behaviour and sufferings were consistent with a diagnosis of the early stages of a Borderline Personality Disorder (301.83), characterised by unstable, intense relationships,
unstable identity and impulsivity in regard to substance use and sexual relations.
Axis 4
Parent-child relation problems in (V61.2)
Phoebe had disrupted relations with her parents from about aged 8.”
Partner Relational Problems
Phoebe had a pattern of becoming involved with older men.”
The relationship with Antony was also marred by episodes of binge drinking and smoking pot.
After these episodes, she would be full of depression and remorse.
Treatment
At first contact Phoebe explained that she had been taking Efexor XR 37.5 tablets, plus 12.5 daily, prescribed by her GP. In the past she had been treated with Cipramil. T commenced Lexapro, initially 10mg increasing to 20 mg daily, because of her depression. At times I prescribed valium for short term use to help her when she was in withdrawal state’”.
Treatment also included a strategy designed to manage substance and alcohol abuse, which
included attendance at AA meetings. This was sometimes successful but after a period, Phoebe
would report a return to, ‘binging’.
A further goal was to seek to help Phoebe manage a stable relationship with Antony. As at
December 2009, Dr Churven felt some progress had been made.
Many sessions were held concerning the breakdown of her parent's relationship. Relations
with both of her parents were seen to have improved during therapy.
Efforts were made to assist Phoebe to establish a career out-let for her, many talents.
Suicidality
From the outset, Phoebe described feeling suicidal at times. These occasions usually followed
periods of either binge drinking or relationship difficulties, ie. when she was drunk or feeling
© history and suggested reasons for this disruption do not justify further examination in this finding.
he history of this behaviour does not warrant further examination in this finding.
® See Dr Churvens report al exhibit 42 page 218.
remorse after drinking. She never described a suicidal plan. During his time with her, Dr
Churven was never concerned that she wanted to take her own life.
Conclusion Dr Churven commented that when Phoebe,
‘was caught in a conflict about relationships and she had resorted to her usual strategy of dealing with her feelings by becoming intoxicated,,.At such times her judgement was
predictably dysfunctional’.
At the conclusion of his consultations with Phoebe, Dr Churven, felt that some progress
towards a successful outcome had been made,
Joanna Young® (Ms Young)
137,
139,
Phoebe’s psychologist Ms Young testified that she was a generalist psychologist, as distinct from a clinical psychologist, and that she was a member of the Australian Psychology Society, now in her 5“ year of practise. She further testified that while not a clinical psychologist she had undertaken training in assessment and diagnosis. She felt able to deal with the issues that were raised by Phoebe, and confident in her analysis.* This was the reason why she had not referred Phoebe for a further clinical assessment to a psychiatrist or other suitably qualified person, (this in the context of her diagnosis, which involved a major Depressive Disorder, Anxicty disorder and Elements of Border Personality Disorder). I further note here Ms Young’s later evidence (transcript 455), was to the effect that at the relevant time she had little knowledge about Border Personality Disorder. In these circumstances, I direct my self to
attach little weight to her assessment of this condition.
Background concerning Phoebe
Ms Young testified that she saw Phoebe on a total of 26 occasions, over 10 months from
February 2010, to 29 November 2010.
She diagnosed:
Major depressive disorder, severe but without psychotic features;
Social Anxiety Disorder with symptoms of generalised anxiety;
Alcohol Abuse;
S| Transcript page 430,
143,
144,
147,
Partner Relational Problems;
Elements of Borderline Personality Disorder, and
Cocaine misuse and prescription drug misuse (sleeping pills).
Ms Young described Phoebe as an extremely sad young woman whose low sclf worth verged on self-loathing. She reported a history of depression and anxiety since 14 years. She further described how her depressive symptoms fluctuated over the course of the therapy and were exacerbated by her continuing misuse of alcohol, and illicit drugs. This was part of the way
she had tried to cope with her interpersonal stressors, social anxiety and her self-loathing.
She often felt misunderstood by those who were close to her and harboured a lot of anger as a
consequence. She saw her self as a failure and felt hopeless about her future.
She had difficulty sustaining close relationships both intimate partner relationships, or
friendships with others.
Phoebe reported taking Lexapro an anti-depressant medication prescribed for her, as well as
valium.
Tn oral testimony Ms Young further testified that ‘Partner relational problems’ referred to at
item 4) in her diagnosis report was a problem presented during the whole of her period of
' consultation, ic indicated from the first consultation, which took place in February 2010."
Specifically on the 15" November, ‘her mood was low, she was teary. She didn’t know what to do (in terms of the relationship)... She drank. Her partner got upset. She felt that she had to
atone and that it was all her fault,”* And more generally:
‘She had told me she was unhappy, that she felt her partner’s attitude was that... “When T try to be me it is not right for him”. She felt that he pul her down and behaved rudely to her in public, makes her feel that that she is wrong or stupid and that things are her
fault...she rarely says something because he becomes defensive or aggro ad
According to Ms Young on the 15 November 2010, Phoebe was still undecided concerning whether she should go with Antony to Paris.
© 1 note that the evidence from all witness tends to establish that Antony and Phoebe had been together for slightly longer than 12 months, at time of the commencement of her consultations with Ms Young.
% Transcript page 409-10
argument she had moved out, and then come back to give it another go.
e® Tuesday 30 November 2010, phone contact with Phoebe.
not want anyone to see her as she was.
lL asked her to write down the phone numbers for crisis lines she could call, (Suicide help-line, Life-line and Direct- line). She wrote them down, (I think she said she did)..., and agreed to call them and get herself to the Alfred Hospital, if she continued to feel unsafe. She said however that she thought she would take some sleeping pills to sleep away the time and her pain, and I urged her to go to hospital instead’. ®
such circumstances it would have been appropriate for her to contact a CAT team.*”
e General observations
‘put in place.
also contacted her GP’s office, where she remained connected for 46 scconds.**
55 See exhibit 8, See also discussion of this telephone conversation at transcript from page 414.
57 Ibid page 416.
159,
Ms Young agreed with Counsel Assisting that Phoebe’s earlier use of five of Antony’s sleeping pills on 2 August 2010, following an argument (‘7 just wanted to sleep and be out of it’)®, coupled with her phone conversation statement regarding her plan to access his sleeping
tablets again, was an additional cause for concern.
She further agreed that she did not follow the matter up with Phoebe on the following day or days. Her additional testimony was that she could not contact Phocbe’s family or friends because she did not have their phone numbers. And more particularly, that any such contact
would breach Phoebe’s right to confidentiality.
With reference to her belief that Phoebe displayed some characteristics, which were similar to borderline personality disorder, Ms Young testified that one of the characteristics of the condition was a demonstrated inability to pick ones sclf up after a bout of depression. Another characteristic of the condition, (also seen in Phoebe), was that she was pronc or more prone to erratic or impulsive behaviour and more likely to build up in her own mind the importance of
something, which may actually have been quite trivial.
‘The inability to regulate feelings is perhaps consistent with borderline.”
Ms Young further stated (like Dr Churven), that in the time she treated Phoebe she never felt she was at risk of suicide, pointing out that she only talked about suicide (suicide ideation), while recovering from binge drinking or relationship difficulties, but she had never been,
‘actively suicidal...°”"
In additional testimony, Ms Young stated that Phoebe’s inter-action with various persons on the Wednesday tended to suggest that she was less distressed than on the previous day, the day
of their phone conversation.”
She was not able to offer an opinion as to whether Phoebe was suicidal on the day following but she was surprised with what occurred. She didn’t think that Phoebe would have killed herself.
Ms Young further offered that Phoebe’s poor financial state was a primary cause of her
anxiety and that she felt that this issue was a big part of her underlying depressive illness.”
%8 Ibid page 417.
® Ibid page 407.
Transcript page 422.
*! Transcript paye 423. Prior to her testimony, Ms Young was not aware of Dr Churven, or the contents of his report.
Transctipt page 430.
® Transcript page 425.
Phoebe also felt unhappy that she was not an equal partner in the relationship and fell quite dependant. She was highly anxious at many of the functions they attended.”*
Further, Phocbe’s financial situation caused her to lose confidence in her ability to pull away
from Antony, and forge a life for herself.* Counsel for Mrs Handsjuk
In further examination by Mr Moglia of Counsel for Natalie Handsjuk (and assisting Dr Handsjuk), Ms Young stated that she was not comfortable in discussing ‘transference therapy’, and further that rather than transference therapy that borderline personality disorder
is normally treated with, ‘dialectical behaviour therapy’.
At the time, Ms Young had had no training in that kind of therapy.”® She further agreed that at that time, she did not know much about the condition. She further agreed that there was now recognised to be an overlap between depression and border personality disorder, as co occurring illnesses. She did not dispute Counsel’s suggestion that this may occur in up to 60%
of cases,
She further considered that Phoebe’s use of alcohol and illicit drugs were indicators of impulsivity, which was an element of borderline personality disorder. Impulsivity in regard to
her relationships, was another such example, as was her intense fear of abandonment.””
Generally, Ms Young saw Phoebe each Monday, on a weekly basis. Some appointments were
postponed because Phoebe was hung over from the weekend.
In regard to Phoebe’s death and her state of mind at that time, Ms Young did not agree that
what she heard on 30 November, may have been a, ‘trajectory towards suicide’.
In regard to Phoebe’s doctors note on 7 August 2010 that she was having difficulty with, ‘Depression, on going problems with medication’. Ms Young stated that she wasn’t aware of
medication issues and that this was a proper matter for her doctor.
Ms Young was then questioned by Counsel on the Australian Psychological Society (APS) Code of Ethics, general principal A5 on confidentiality.”
° Transcript page 427.
°5 Transcript page 429.
58 See reference to her subsequent training in respect of the diagnosis and treatment of this condition, at transcript page 455.
°” Transcript page 436-37.
Having refreshed her memory it was now her understanding that under the code she was
permitted, to breach confidence to the minimum necessary, ‘to avoid an imminent risk’.
The three main things she would tell clients when sessions commence were that she would not breach confidence unless her files were subpoenaed by a court; or unless there is a risk of either self-harm, or harm to another person. The risk must be imminent and serious and this
assessment was carried in a suicide risk assessment.
In this case, Ms Young concluded during the phone conversation on 30 November, that such a risk was present, inferring that both a means to commit suicide and an immediacy about the
plan, then existed.’
Ms Young further testified that at the relevant time she was in a professional (supervision) relationship as allowed for by the code, and that she had been supervised within such a relationship since her commencement of practise 5 years earlier. At the time of her taking the phone call from Phoebe, her supervisor was Kaye Baron, who was her original supervisor,
‘through my two years of probationary registration...,’ Her further testimony was,
‘Tf I had an urgent inquiry I expect could have called her. The fact was that at this time
she was on leave.
Would you have called her if she was available?
Answer: ‘Probably not. Noo!
Ms Young was then asked by Counsel whether Phoebe reference to ‘feeling unsafe’, may have meant that she faced a threat from another person. Ms Young did not understand Phoebe to be talking about another person,'” but rather that she was referring to her alcohol and pill
use, and the risk of harm through that use.!°
Ms Young further advised in response to a question from Counsel for Antony Hampel, that
she had never heard Phoebe refer to the brand name Stillnox.'”* The witness was then referred
'00 See transcript page 448-49.
" Sce transcript page 450-51
102,
See transcript page 459,
1 Transcript page 457. I note here that this interpretation tends to contradict the intentional sclf- harm interpretation, offered by the witness carlicr in evidence, which interpretation is also found in her treatment report at exhibit 8.
See transcript page 461,
' | ; | i
to her handwritten contemporaneous note of the phone conversation, and her reference to,
‘feeling hopeless-what is the point’.
Ms Young was concerned that Phocbe was suicidal.’
In further re-examination, she was asked whether she felt that someone with a combination of elements of a border personality disorder and depression, might do something dramatic, a
gesture like putting themselves into a rubbish bin.
She considered that a person with a full-blown disorder might do something dramatic. She didn’t believe that Phoebe had such a full blown condition.
Ms Young further confirmed that she did not complete a suicide risk assessment when
Phoebe commenced seeing her.
She also did not arrange a plan with Phoebe to allow for crisis intervention, at the commencement of their consultations, or at any other time. She agreed that it would have been a good idea to have done so and that the APS recommended as far back as 1999, that a crisis plan should be put in place to allow for, ‘the focus to move from therapy to one of crisis
management’, where it is believed there is an imminent risk of self harm.’
She further agrecd that it would have been appropriate to put such a plan in place for
someone suffering from chronic depression. -
She also agreed that it would have been appropriate for her to follow up on such a paticnt
afterwards, and that this was something that she now always did,'”
Thereafter Dr Handsjuk, asked for, and was given the opportunity to further question Ms
‘Young. 108
In the course of that evidence, Ms Young testified that she, ‘struggled to explain,’ why she hadn’t followed through and given Phoebe’s situation the sort of ‘gravitas,’ consistent with her explanation of the conversation in question.
‘perhaps I felt the risk was not that great and (not that) imminent’!
Sce exhibit 8(b) and transcript page 464-65.
1° See exhibit 8(d).
At the conclusion of her evidence, Ms Young was informed of her rights in connection with the obtaining of a transcript of
the evidence and about making a submission to the Court concerning her involvement in Phoebe’s care. See transcript page
476,
A submission from her legal representative was subsequently received, and had been included in my consideration of this
case.
108 See transcript from page 473.
Page 34 of 83°
‘That's why I suggested she contact a help line’.
as inconsistent with her assessment that Phoebe was not capable of actualising self-care, to
which question Ms Young did not respond,!'®
Dr Leonard Handsjuk!" e Background concerning Phoebe
to settle down.
that she had been taking Cymbalta, an anti-depressant.
It had also been suggested that she had an alcohol problem. Her drinking had increased when she worked as a receptionist at hair stylist Lindley Godfrey. Dr Handsjuk ceased his practise of keeping a bottle of vodka in his the fridge, to prevent Phoebe from drinking too much.'”
While working for Lindley Godfrey, Phoebe went to see psychiatrist Dr Churven, for about
six months. He prescribed anti-depressant medication.
e The events of 2 December 2010
seeking to establish that his daughter was safe.
1 See transcript page 475 " Ibid,
"1 Dr Leonard Handsjuk is a practising psychiatrist, with over 40 years of experience.
‘2 See Dr Handsjuk’s first statement at Exhibit 42 page 60.
"3 T note that in a sccond statement dated March 9 2611, Dr Handsjuk referred again to his conversation with Antony on the Thursday evening, but did not state that Antony had said that he had found Phoebe’s phone, when he returned to the apartment. See exhibit 42 page 65.
~ Page350f83
Quite shattered, he then went about the duty of informing family members.
e¢ Comment on the Report provided by Dr Churven
psychiatrist, Dr Peter Churven.
depression, he was not aware of the personality disorder diagnosis, before her death.
intoxicated’.!"
194, He was then asked to give his opinion about the impact of an on going depressive illness, coupled with a borderline personality disorder. His view was that such a person would be,
‘pretty non-functional’.
with reality for days on end, and require antipsychotic medication and often hospitalisation.
Discovery and Investigation
were notified at 7.14 pm. Police arrived at the scene at 7.20 pm. At that time, Phoebe was
"4 See transcript page 1363.
found, (believed deceased), lying face up on the refuse room floor a short distance from the single door allowing access in and out of the room. She was dressed in a grey singlet and blue jeans, held by a wide black leather belt. The top of her jeans had been caused to move to a
position below her thighs.
197, The immediate cause of Phoebe’s death was exsanguination following a severe injury to her right leg. Based upon the inferences drawn from evidence of Ms Ozlup, (who found Phoebe at between 7.06 and 7.09 pm), and the Ambulance Officers who later arrived at the ground floor refuse room at a point in time not before 7.27 pm, (see also exhibit 15(b) the police crime scene notes, which suggests the time of the ambulance officer arrival was actually 7.30 pm), Phocbe had been in the same position following her discovery, for a minimum pcriod of 18
minutes, that is before the Ambulance Officers arrived.
198, From the evidence given by Pathologist Dr Lynch, we know that the time before a loss of consciousness would occur, followed then by the time at which the onset of death would take place, is between 5 and 10 minutes. Considering also the evidence of the officers who found her, I find that it is in fact quite clear that Phoebe was deceased by the time the Ambulance
Officers, reached the scene.
Detective Sergeant Butterworth!
199, Detective Sergeant Butterworth was notified of the death at approximately 8 pm, on 2 December 2010, and attended at the Balencia apartments at 8.46 pm.
200, On arrival, he found Detective Sergeant Andrew Healy, Detective Senior Constable Paul Thomas and Sergeant Graham Foster in attendance. He was informed, that a young woman believed to be Phoebe Handsjuk, had been found deccased in the refuse room on the ground floor; that she was belicved to be a resident on the 12" floor and that traces of blood, now secured, had been found in the refuse room on the 12" floor; that what appeared to be traces of blood had also been found in one of two elevators, that serviced the building, which had not been secured;!"* that what appeared to be traces of blood had also been found on the concrete
floor in the foyer level of level B1 (car park), which had not been secured:
201, Detective Sergeant Buttcrworth arranged to tape off and secure both the affected elevator as
well as the affected area in the car park.
"5 Sergeant Butterworth is a Detective Scrgcant attached to the Crime Department Purana ‘ask Force, who attended on behalf of the Homicide Squad. He remaincd the senior officcr in charge of the investigation until his departure from the scene at 5.40 am the following morning, Friday 3 December.
N6 Sco brief page 305.
Detective Sergeant Butterworth was then escorted to the refuse room. He there saw Phoebe Handsjuk, fully clothed, lying face up immediately adjacent to the refuse room doorway. She was not wearing any shoes or socks. I note here that at this time Detective Sergeant Butterworth observed that the top of her jeans had been caused to be moved down to a position around the lower part of her legs. Her most significant injury was the near severance
of her right foot, at a point approximately 2 inches above her ankle.
He also observed and it is not in dispute, that the refusc room consisted of a rotating carouscl
in the centre of the room, on which 5 wheelie bins were meant to sit.
A rubbish chute was suspended above ihe carousel (which we now know covered a computer controlled rubbish compactor), all of which fed rubbish from the above floors into the bins held on to the carousel. One of the bins had fallen from ils filling and come to rest on the floor near to where Phoebe was found. A smeared blood trail was also found on the floor and wall,
which trail extended around the carousel.
Later Detective Sergcani Buticrworth also made arrangements lo seek to prevent residents
from continuing to put rubbish down the chute, while scene inquiries were continuing.
He then debriefed Detective Sergeant Andrew Healy concerning his earlier dealing with Antony Hampel, who had approached him at 8.10 pm with seemingly relevant information concerning his then missing girlfriend, and the possible relationship of this matter to the identity of the woman found deceased.
Detective Sergeant Butterworth further stated that he then took steps to obtain a copy of the
Balencia Apartment’s closed circuit TV tape, for that day.!!”
At 10 pm Detective Sergeant Butterworth briefed Leading Scnior Constable Bernard Carrick from Victoria Police Forensic Services Department, as to the situation as he then understood it
to be. Leading Scnior Constable Carrick commenced to process the scene.
Photographs were taken of the scene including inside the apartment, and inside the refuse rooms on the 12" floor and the ground floor. Phoebe was photographed from various angles at this time.
Swabs were also sought by Leading Senior Constable Carrick from possibly relevant areas, including in respect of blood stains found in the apartment, on the floor of the refuse room on
the 12" floor, as well as inside the whcclic bin, into which it is belicved she fell. Additionally
''’ See exhibit 19 the statement of Detective Sergeant Butterworth, at page 6.
214,
217,
swabs were taken from the floor and walls of the ground floor refuse room, where she was
found.
Statements were taken from Antony Hampel, Dr Leonard Handsjuk and Phoebe’s brother, Thomas [andsjuk.
At 2.40 am, the Government undertaker removed the deceased from the scene. At this time Detective Sergeant Butterworth observed a number of cuts and abrasions to her legs back and
buttock area, as well as the obviously severe injury to her right leg, which he had seen earlier.
At 4.55 am, fingerprints were also sought from all relevant areas, including the entry to the refuse chute in the 12th floor refuse room. Leading Senior Constable Koslowski, an
experienced crime scene examiner, under took this work.
At 5.40 am, Detective Sergeant Butterworth cleared the scene and returned to the St Kilda Road Office, where he later briefed and handed over to Detective Senior Sergeant Shane
O’Connell of the Homicide Squad.
In further testimony the witness stated, that the Purana task force, of which he was a member, provided support to the Homicide Squad by attending the scene on the night in question, because Homicide Squad officers were otherwise engaged at that time. During the period following notification of the death and before his arrival, Detective Sergeant Butterworth was engaged in organising his crew, making calls to arrange for the scene attendance of officers from Crime Scene Services, notifying Coronial Services and speaking to the Duty Pathologist.
On arrival al the Balencia building, Sergeant Healy informed him of a finding of suspected
blood traces in the residents lift!!®
According to his log, Detective Sergeant Butterworth was also in the refuse room when he heard and observed a plastic bag come down the rubbish tube, and into a plastic wheelie bin. |!’ He was not sure whether the machine was off or on at that time. Thereafter he organised for signs to be placed in each of the refuse rooms above,
requesting residents not to use the chute until Police had cleared the scene.
He further agreed that following determination of Phoebe’s identity and place of residence,
that all occupants of that apartment should have been removed. And that following receipt of
"8 The blood spots found on foyer tiles level B1 and inside the lift at level BI, were swabbed and later found to be consistent with having come from Mr Joseph Grech (statement at exhibit 42 page 40), who was a cabinet maker, who had cut himself on December 2, while in the course of his labour in the apartment basement. See exhibit [6 page 3, (See brief page 333-37). Mr Grech was ruled out of being the source of any other blood collected at the scene,
"? This occurred at approximately 9.22 pm. Sce transcript page 839. At the time the compactor machine was still in operational mode.
223,
advice that blood had been found in the 12" floor refuse room, that he would have so informed
Leading Senior Constable Carrick, an experienced crime scene examiner. !?°
Detective Sergeant Butterworth further offered that in regard to the investigation and the Balencia Apartment’s closed circuit TV tapes, that he had no knowledge of the building manager, Mr Eric Giamarrio, informing police officers on 2 December, that there was a need to start down loading that material as soon as possible as the tapes would be recorded over in
two to three days time.
Detective Sergeant Butterworth was unable to recall if inquiries were made of the two officers who had seen some of the CCTV tapes, as to the potential value to the inquiry of downloading
the tapes for later examination.
No arrangements were made for Police from the Forensic Science Department to come out and retrieve any of the then existing footage, this was because another officer at the scene, had
already been directed to arrange for the existing tapes to be copied.'”'
He had no recollection of the note at page 1022 made on 7 December, 11 am, that he personally received CCTV from Eric Giamarrio,'” [ note here that this note appears to refer to the limited materials for 2 December 2010, actually received from the Balencia corporate manager, (who at its own expense later sought to retrieve as much relevant tape as possible, ic. after the taping over process had taken placc). His further evidence was that at some point while in the apartment he noticed the [Mac computer (shared by Phoebe and Antony), and that the computer mouse had some blood on it, but that this was not taken into custody as it had not been established that a crime had been committed. At the time of his departure from the scence, Detective Scrgcant Butterworth, ‘was leaning towards suicide’, as an explanation for
the events that he had so far examined.!”?
Information obtained at the scene about Phoebe Handsjuk and her family and other relevant background, (which was consistent in its content), came from Antony Hampel, Dr Leonard
Landsjulk and ‘Thomas Landsjuk.
His further testimony was that no attempt was made to seek to link the rubbish bag contents found in the bin into which it was believed Phocbe had fallen, with the apartment in which she
had resided. Additionally that no information was obtained concerning whether Mr Hampel
2° See exhibit 19 page 9 and transcript page 844.
"| Sce transcript page 846-47.
2 See transcript page 886.
"3 See transcript page 852-53. The underlining is mine.
224,
225,
227,
228,
229,
had returned to the apartment after work, and found the front door open, or otherwise closed
and or locked, (thus requiring a key for re-entry).
Detective Sergeant Butterworth worked through the night and signed off at 9 am on the morning of 3 December 2010, having orally bricfed Detective Senior Sergcant Shane O’Connell. At that time, Detective Sergeant Butterworth believed that he would have
indicated his view that the death was morc likely to be suicide than homicide.
From this point Detective, Senior Sergeant O’Connell looked after the investigation. The outstanding issue in respect of the CCTV would also have been mentioned to Detective Senior Sergeant O’Connell at this time. This evidence would have been considered important to any
homicide investigation, !™
Concerning the evidence that an Ambulance Officer was not permitted into the refuse room to examine Phoebe for signs of life, Detective Sergeant Butterworth had not arrived at the scene by the time this event took place. By the time of his arrival (8.46 pm), it seemed clear that
everyone present had the strong view that she was deceased.’
Detective Sergeant Butterworth continued his inquiries on behalf of the Homicide Squad on the following Monday and ‘Tuesday. ‘The notes that he made on the night of 2 December 2010, have not been able to be located.!° In response to further questions from Counsel representing
the Commissioner for Police, the witness testified concerning CCTV footage, that it would be
“usual to ask the owner to provide the footage rather than to take possession of the computer
hard drive, which in this case would have adversely impacted upon the buildings security.
He had not heard Mr Bone, the chute systems designer, say to Police that if the, ‘unit had been in auto mode it would have been necessary for someone to switch it to manual for a body
lo pass through in one piece’””
And that during his handover to Detective Senior Sergeant O’Connell on 3 December, he did make mention of the surrounding circumstances he had discovered to that point, which matters
he felt were not consistent with suicide.
4 Sce transcript pages 860 -862.
as
See my comments at transcript page 878 where in disallowing a question put by Counsel for Mrs Handsjuk, it was
observed thal a question designed to establish that police officers might have excluded Ambulance Officers from cxamining Phoebe in the refuse room to preserve the scence presumes,
‘a fact which would be hard to comprehend, that is that police officers would put the interests of the investigation above the interests of the life and death of a victim’.
See transcript page 876.
See transcript page 884,
| | |
Leading Senior Constable Bernard Carrick
He observed the severe injury to her legs in particular in the region of her right foot. He also observed a large amount of smeared blood on the floor and its proximity to an automated
wastc machine that was centred inside this room.
Prada sunglasses on the ground near her body.
Swab samples of these bloodstains were also taken.
Further swabs were taken of apparent bloodstains on the 12" floor at the refuse room and within the apartment. Medication, glass fragments, and various hand written notes and a post it note pad were taken away for forensic examination.’
Senior Constable Martin Koslowski'”®
examination for latent fingerprints at both the 1* and 12” floor disposal rooms.
Leading Senior Constable Scott Ellis'*”
both the 1% and 12" floors referred to in the narrative set out above. A total of 148
8 See LSC Carricks statement at exhibit 17.
2 Sco SC Koslowski’s statement at exhibit 42 page 318,
80 See statement of police photographer LSC Ellis at exhibit 42 page 320 and the photograph descriptions by number set out therein,
~~ Page 42 of 83
photographs were produced into evidence during the testimony provided by Forensic Officer T.ouise Brown, and became exhibit 16(h).
Leading Senior Constable Darryl Saint!*!
Lorne Campbell'*
‘written off Phoebe’s death as a suicide’.
239, He considcred this premature, and determined to investigate the death himself. He also considered that in the unlikely event that she had determined to kill herself that she would not have chosen to do so by climbing into the refuse disposal shaft. He later visited the apartment block and viewed the refuse entry on the 24" floor. His further view was that given her blood alcohol was measured at 0.16%, Phoebe, ‘or any one at that. level of intoxication would not
have the necessary level of balance and co ordination to climb unaided into the chute’.!*
be of similar weight and sizc, and a representative of the buildings corporate manager.'4
241, At the scenc, Mr Campbell secured each woman against injury before separately asking each to climb into the chute, unassisted. They both managed to do it with difficulty, and the
exercise was video recorded.
? Lorne Campbell, the maternal grand father of Phoebe, is a retired Detective Sergeant having been a sworn police officer
with Victoria Police, between 1959 and 1993.
83 See statement of Lornc Campbell at exhibit 7 page 1.
™ Mr Campbell considered that the 166 cm height as measured prior to her PM was incorrect, and that Phocbo’s true height as recorded by her mother was not less than 175em. | further note that one of the two young womcn, Sara Howett, was
described by Mr Campbell as a person with whom Phoebe trained, ‘over a long period in martial arts and kickboxing’.
5 See exhibit 7(e)
|
245,
247,
I note here that they both were able to sit on the back of the chute entry and hold their positions with their feet extended into the shaft. They were not asked to, and did not climb into
the chute itself. °°
Later Mr Campbell went to the Westach Engineering Services Lid at Hallam, and spoke with
company managing director Mr Neil Bone.
‘He was familiar with the matter... and was very concerned about it. He told me that another party must have been involved as it would not have been possible for Phoebe to pass through the compactor with the system in its normal automatic operating mode. He
said he had informed police but... they appeared disinterested’!””
Mr Campbell then explained to Mr Bone the nature of the experiment he wished to conduct
and Mr Bone offered to sct up an exact replica of the wall and disposal hatch.
Later on Friday 18 February 2011, Mr Campbell together wiih Sarah Howlett, Viviana Bambino, Natalie’s Handsjuk’s friend, Russell Martiot and Jeannette Campbell, returned to the Hallam factory.
Both Sarah and Viviana were asked to climb into the model chute. Sarah was unable to do so because of her shoulder width while Viviana managed to get into the shaft, with great difficulty and emerge from the open bottom section of the model, which was elevated and
resting on a stecl frame.
A further experiment with Viviana lifted in a shoulder lift by Russell Marriott, and placed into the chute facing the chute wall, with her arms above her head was achieved quite easily with
Viviana passing through the through the chute opening, and into the shaft.'*
Although the tests established that it was possible for a sober person of appropriate size to get into the chute entrance down into chute proper, Mr Campbell remained firmly of the opinion
that such a feat would not be possible for a person with a 0.16% blood alcohol reading.
Certain further criticisms were made of the Homicide squad by Mr Campbell.
These included that officers had not taken a stalement from Mr Neil Bone and that officers had also failed to take possession of the apartment building’s computer hard drive, containing all recordings made by the CCTV system within the building, with only a small portion relating to the foyer and building entrance still available, in respect of 2 December 2010.
87 Thid,
See further discussion of Mr Campbell’s observations at exhibit 7(c) page 2.
8 See video at exhibit 7(f).
257,
258,
One of the CCTV cameras took in a view along to the entrance of the refuse collection room on the ground floor. In view of Mr Bones advice and the inference that someone must have entered the refuse room from the ground floor entrance, (to turn off the compactor), Mr Campbell considered that the loss of the CCTV evidence, had the potential to deny the
investigation material, which might become vital identification evidence.
Detective Senior Constable Payne co-operated with Mr Campbell and provided telephone
records and phone log records. He invited Mr Campbell to contribute to his own investigation.
Mr Campbell and Natalie Handsjuk then prepared a chronology of events as they saw them, which became exhibit 7(b) and I note here, later became the subject of a prohibition from
publication order.
Mr Campbell together with Natalie Handsjuk then determined 1o covertly record conversations later had with Antony and his family at Antony’s apartment where they visited on Tuesday 7 December. These conversations were primarily concerned with the plans being made for Phoebe’s funcral and the tensions between the two families, which arose over that matter, (Having listened to and again reviewed these materials, T am satisfied that the materials
and commentary are largely conjectural, and are not relevant to the questions now before me).
Mr Campbell also raised the point that Antony’s alleged return to the apartment to check’on Phoebe, on the morning of Wednesday December 1, was believed to be untruthful. (I note that we now know that Antony’s recollection concerning this matter has been verified by the evidence from his card swipe suggesting, as il does, that he entered the building at 12.40 pm
and stayed for approximately 10 minutes.
Mr Campbell also considered. that cushion stuffing, as well as a broken glass found on the floor of Antony’s apartment was consistent with a scuffle. In addition, that bruises to Phoebe’s person were consistent with an assault. He concluded that this was not a case of suicide, accident or misadventure, but rather that she was, ‘criminally killed’, and thal the investigation
should continue until those person(s) responsible could be identified.!°
In oral testimony, Mr Campbell further stated that the 12" floor, system entrance door had
two strong return springs.
He also considered that the police should have taken both computers from Antony’s
apartment on the night of December 2.
9 Soc exhibit 7 at page 8.
259,
In response to questions concerning the design of the chute he confirmed that at least one of the two young women obtained a (narrow) hand-hold at the top of the chute entrance, when climbing in.
He also stated that the swipe records he relied on to establish that Antony had not returned to the Apartment to check on Phoebe on the Wednesday, were found at brief pages 901-904, Mr Campbell was further questioned by Counsel for Antony Hampel, about his examination of the corrected swipe card documentation, and agreed that this material met earlier concerns
about Antony’s movements on the Wednesday.
Mr Campbell answered further questions about his investigation and his interviews of several persons who provided statements to police. These included Ms Ozulup, Mr Giamarrio and Mr Bone. He later confirmed in response to questions from Counsel Assisting, that beyond the material contained in the inquest brief that there was no further information or documentary evidence he had, that would assist the inquest and that he had nothing further to say in respect
of the matter,‘°
Mr Campbell further testified about attending an experiment organized by media organisation Channel 7, Melbourne, which involved putting two lamb carcasses into a chute and dropping them into a compactor from the 12th floor, in an apartment block under construction, and the
extensive damage done to the carcasses as a result.!"!
He also agreed that the evidence Phoebe’s iPhone went in for repairs on the Thursday 2 December 2010, rather than the Wednesday, (as referred to in an earlier statement by Antony),
was corrected in a statement made by Antony as early as 7 December 2010.
He also accepted that page 90 of the exhibits brief, the telephone records indicate a phone call was made by Antony at 11.34 am on 2 Deccmber 2010, from the Abbotsford South area, which was in the vicinity of the phone repair shop and that Phoebe sent an email message to her former leciurer Vin Ryan, at 8.13 am that morning, which was within minutes of Antony leaving the building (at 8.11 am), and well before the text message, sent at 10.30 am to family
members.
“0 See transcript pages 348-49 and 359, The audio record was evidently unable to record the answer given to Counsels question by Mr Campbell. The answer given by Mr Campbell (and subsequent answers), were to the effect that he was not in possession of further information or documentation, which he believed might he of relevance, or otherwise assist the Court,
‘| Soe transcript page 354, Sce also discussion with Counsel at pages 355-57, concerning the relevance of this evidence having regard to the absence of evidence establishing parallel conditions, and the evidence conceming Phocbe’s movement through the chute, and the relatively limited injuries she sustained as a result, He also agreed that there had been no evidence collected concerning the height and weight of the two young women who assisted with the event reconstruction. Sec transcript
page 371.
IT note here that this evidence (transcript 369-70), was presented by Counsel for Antony, to corroborate Antony’s evidence that he was not in possession of Phoebe’s phone on Wednesday December 1, at the time (Phoebe) sent her message to family and friends, which
message is sct out above at paragraph 46. -
Forensic Officer Louise Brown !
269,
270,
Officer Brown, received blood swabs taken at the scene and after making appropriate comparisons including DNA analysis, she concluded that the blood stains found in the study room doorway within the 12" floor apartment; the blood stains found within the 12" floor refuse room; the blood stains found on Phoebe’s clothing; the blood stains found on the floor of the ground floor refuse room and on the ground floor wheelie bin; - were all consistent with
the blood profile of Phoebe Handsjuk.
Officer Brown examined the damaged clothing and further opined that the jeans were extensively damaged and stained with apparent blood, on both the inside and outside surfaces.
The underpants were also heavily bloodstained.
Concerning the transfer stains on the doorway to the study, that transfer stains were observed on the architrave of the doorway. Transfer stains were also observed on the desk and
computer mouse pad.
In regard to the blood stains found in the 12" floor refuse room, there were transfer stains on
the floor near the chute, with some of these stains having a smeared appearance.
Concerning the blood stain pattern analysis found in the ground floor refuse room her further advice was that based on her own opinion, (and that of a second authorised scientist), the body of Phoebe was located between the wall and the fallen bin to the right of the door opening, as the room was entered. There were transfer stains on the lower portion of the wall in proximity to her legs. The floor towards her feet was heavily smeared with blood, amongst which, were numerous swipe marks with apparent toe impressions. The clothing around the lower portion
of her body was saturated with blood.
There was also flesh type tissue and transfer stains found on the opening of the garbage chute.
There was smearing and pooling of blood in the area of the drain with swipe patterns moving
™ Forensic Officer Louisc Brown is employed at the Forensic Services Centre Macleod Victoria, as a senior case manager and Reporting Unit Leader within the Biological Examination Branch. She has certificates of authorisation issued by Forensic Services, (the FSD) allowing for blood-stain pattern interpretation and for the reporting on and analysis of biological material in a number of genetic marker systems, She is the holder of a BSc (Hon) and in 2008, successfully completed a course in Forensic DNA profile interpretation, at the University of Washington. She has assisted with scientific examination and interpretation in over 130 cases including homicide and alleged rape scenes and given an opinion concerning more than 300 criminal investigations, across all jurisdictions.
|
in an anticlockwise direction away from the door. There were areas of pooled blood and
transfer stains to the sides of the swipe blood trail.
There were transfer stains with swipe features to the lower portion of the back of the door.
Inside the bin that had been overturned, there were transfer, swipe and pooled bloodstains.
There was significant staining to the floor of the ground floor refuse room with the staining observed consistent with an individual with bleeding imjurics, dragging themselves in a
clockwise direction around the room.!*4
Mt Neil Bone™
Mr Bone gave several accounts of how the incident may have occurred. His initial belief was that unless the system had been placed on manual, (suggesting the involvement of a third party) Phoebe would have sustained far more serious injury, as she was released from the
compactor into the refuse bin.
With further thought and information, he later surmised that the injuries she sustained were possible with the compactor remaining in auto mode, (which he found had occurred). His evidence was that an object or person passing through the compactor would activate a light sensor, which in term would operate the compactor blade. The compactor blade is designed to compress the rubbish bags with substantial force (hydraulic cylinder exerting a force of 3.3 tonnes) in order to form a plug ready for release into a static wheelie bin on a rotation device.
There were at least two possible ways for her to be ejected. Firstly, the unit formed the view it
was full and the blade could not compress the material any further.’
Her injuries appear to be consistent with the operation of this compactor unit as described by Mr Bone, which operation allowed for her to pass through the compactor and be released into the wheelic bin. Sce also the examination of Dr Lynch on the issue of her injuries and passing
through the compactor, by Counsel assisting at page 65 below.
Dr Mathew Lynch"
Dr Lynch noted from information supplied by Detective Sergeant Butterworth, that Phoebe
had been found deceased in ground floor refuse room at the St Kilda Road Apartment block in
"3 See transcript page 701.
“4 fr Bone was the compactor system designer and assisted with the investigation of Phoebe’s death.
Secondly, (although less likely), that the unit had reached a maximum bag count and anything further would have been
ejected at that time, See also examination of Dr Lynch by Counsel Assisting at page 65 below.
“8 Dr Mathew Lynch is a senior forensic pathologist at the Victorian Institute of Forensic Medicine and an honorary senior lecturer in the Department of Forensic Pathology at Monash University. Dr Lynch commenced his autopsy examination on Phoebe Handsjuk, at 1200 hrs on Friday 3 December 2010. His report became exhibit 26
jeans extensively blood stained and situated below her knees. She had resided on the 12" floor with her partner and had last been scen alive at around midday. It was suggested that she may have entered the chute on the 12th floor and fallen to the ground floor. It was further believed that she had a history of depression and alcohol abuse. It was also reported that she had been found at 7 pm and that there was a large amount of blood found on the floor of the
refuse room where she had been found. Dr Lynch did not attend the scene that evening.” External Examination e Head
On the right side of the forehead a yellowish parchment change, which may have been a post
mortem artefact measuring Ix 0.2 cm was located.
On the forehead in the midline region some scattered abrasions measuring up to a maximum 0.2
cm.
A lem abrasion over the left ear and a linear abrasion 1 x 0.1 cm with adjacent bruising.
© Neck
An area (at the front of the neck) of 1.5 x 0.2 em of bruising.
e Chest
No injuries were noted anteriorly or laterally. Linear abrasions to the right chest wall measuring
up to a maximum of 5 om, were observed.
Tn the lower thoracic region extending to the lumbar region of both sacroiliac joints there were
muttiple abrasions some of which had a distinct lmear appearance.
What appears to be dirt or other foreign material is deposited over the lower thoracic and lumber
regions I association with the abrasions. See photo 64 at exhibit 16(h) scene photographs.
. Abdomen
There arc a number of injuries on the lower abdominal wall. In the right iliac fossa an injury with complex bruising with abrasions measuring 9 x up to a maximum of 3 cm, with a further
superficial laceration at the centre of the injury complex of 1x 0.2 cm.
“1 See exhibit 26 at page 1.
Tn the left iliac fossa extending to the left iliac spinc and ihen onto the lateral aspect of the leit hip an injury complex which comprises a laceration measuring 4 x 2 cm with an abrasion which extends medially and measured 4 x 0.5 cm. This extends down to the underlying skeletal muscle
but does not enter the peritoneal cavity.
In the suprapubic region there are several linear abrasions with associated bruising in a linear distribution extending from below the right anterior supcrior iliac spine to a similar point below
the left anterior iliac spine.
Right Upper Limb
Scattered abrasions on the posterior right elbow extending along the ulna aspect of the right
forearm.
A lincar abrasion on the dorsal aspect of the right hand overlying the dorsal aspect of the right
hand overlying the proximal part of the second metacarpal measuring 0.3 x 0.1 cm.
Abrasions with bruising over the dorsal aspect of the right fifth metacarpophalangeal joint.
Minor bruising and abrasion injury to the right shoulder, and a bruising injury to the dorsal
aspect of the right wrist.
Left Upper Limb
Scattered bruises over the superior, lateral and anterior aspects of’ the left shoulder, the total
injury complex measuring up to 10cm in maximum dimension.
An abrasion on the posterior aspect of the left shoulder measuring 3 x 1 cm.
Scattered bruises and abrasions over the posterior aspect of the left elbow.
Scattered abrasions on the ulnar aspect of the left forearm.
Bruising dorsum left wrist 2 x lem.
Abrasion dorsum left hand over the first metacarpophalangeal joint O.lem in maximum
dimension.
Left lower limb
There is extensive bruising with swelling and multiple abrasions and a laceration 1 cm in maximum dimension situated over the anterolateral aspect of the left hip extending onto the
left thigh where there is also bruising on the medial aspect of the mid to proximal left thigh.
Bruising, abrasions and lacerations anterior aspect left knee the total injury complex
Scattered bruises anterior left lower leg. Abrasions and lacerations dorsal aspect left ankle with a laceration measuring up to 3 cm in maximum dimension resulting in exposure of underlying tendons. Laceration dorsal aspect left great toe extending medially and onto the
plantar aspect with associated disruption of tendons.
Extensive bruising dorsal and lateral aspects left foot with abrasion lateral aspect left mid foot extending onto the plantar surface. Note:- there is a large amount of dried blood present on the
plantar aspect of the left foot.
Multiple areas of bruising over the left buttock some of which have a somewhat linear
distribution.
Right lower limb
Abrasions and bruising anterior, lateral and medial proximal right thigh. Abrasions, bruising
and lacerations anterior right knee.
Multiple abrasions and lacerations right lower leg with palpable fractures of right tibia and fibula.
The right foot is virtually completely traumatically amputated from the distal right lower leg at the level of distal tibia and fibula. The foot remains attached to the limb by muscle tendon alone, All skeletal muscle and blood vessels have been disrupted. The margins of this injury teveal the skin to have regular edges in places associated with some abrasion suggesting the application of some form of blunt force. The ends of the fractured tibia and fibula are
fragmented and irregular.
Multiple areas of linear and discoid bruising over the right buttock extending to the medial
aspect of the buttock.
Blood on plantar aspect of foot.
Back
Over the right scapular region there is an abrasion 3 x 2 cm.
Internal Examination
Cardio Vascular System
Heart: 265 g.
Pericardium: Unremarkable. The pericardial cavity contains a small amount of serous fluid.
Epicardium: Unremarkable.
Myocardium: No macroscopic evidence of previous or recent ischaemic damage.
Endocardium: Unremarkable. No atrial or ventricular septal defect. Foramen ovale is probe patent.
No subendocardial haemorrhage.
Cardiac valves: No evidence of vegetation, stenosis or other abnormality.
Coronary arteries:. Normal anatomy. Left dominant circulation. Minimal atheroma.
Aorta and its major branches: Minimal athcroma. Aorta intact.
Mediastinum: Unremarkable. No evidence of mediastinal haemorrhage.
Respiratory System Pleura: Both pleural cavities contain are dry.
No haemothorax. No effusions.
No haemorrhage on the parietal pleura.
Larynx: The hyoid bone and thyroid cartilage are intact. Strap muscle dissection
performed.
No strap muscle haemorrhage noted.
Trachea and Bronchi: Contain some blood stained frothy fluid.
Lungs: Right lung 366 g., left lung 308 g. Both lungs are of normal weight and
are pink in colour showing minimal anthracosis.
Minimal fluid can be expressed from their cut surfaces. The visceral pleural surfaces are intact. Neither shows any macroscopic cvidence of
an infective or neoplastic process.
Pulmonary Arteries: Intact. Free of thromboembolus.
Diaphragm: Intact.
Gastro —Intestinal System Peritoneal cavity: | Contains a small amount of serous fluid.
No haemoperitoneum.
Ocsophagus: Unremarkable.
Stomach: The stomach contains 100 ml of tan fluid. No drug residues are identified
macroscopically.
Mesenteries: Unremarkable.
Duodenum: No ulceration.
Jejunum and Tleum: Opened in their entirety. Unremarkable.
The contents comprise tan fluid.
Appendix: Present.
Colon & reetum: Opened in their entirety. There is no mucosal abnormality, tumour,
haemorrhage or melaena present. The contents comprise firm tan facces.
Liver: 1101 g. Capsular intact and smooth.
Cut surface unremarkable.
Pancreas: Unremarkable. Minimal autolysis.
Gallbladder: Thin-walled and contains a small amount of bile. No calculi.
Bile ducts: Not dilated.
Reticuloendothelial System
Lymph nodes: No lymphadenopathy detected.
Spleen: 57 g. ‘The capsule is intact. Cut surface unremarkable.
Thymus: 16 g. Unremarkable.
Endocrine System
Pituitary gland: Unremarkable.
Thyroid gland: 11 g. Unremarkable.
Adrenal glands: Unremarkable.
Genito Urinary System
Kidneys: Right kidney 127 g., left kidney 124 g. Both renal capsules strip with ease revealing smooth cortical surfaces. There is good corticomedullary
definition.
The renal pelves are not dilated. Ureters unremarkable.
Bladder: Contains a small amount of yellow urine.
Uterus: Uterine tubes and ovaries: The uterine tubes are unremarkable. The left ovary measures 4 x 4 x 2 cm and on sectioning contains a unilocular cyst 2 cm in diameter containing clear fluid. The right ovary is of normal size
and contains a corpus luteum.
The uterus is of normal size. The uterine cavity is empty. The endometrium is soft and light brown in colour and measures 1 mm in thickness. No hacmorrhage. Cervix unremarkable. Vagina unremarkable.
No evidence of haemorrhage, Breasts: No mass lesions identified.
Musco Skeletonal System The following fractures were identified.
No evidence of skull or spinal column fracture. There is intramuscular haemorrhage involving the left temporalis muscle. There is also extensive haemorrhage involving the quadriceps femoris muscles on the left and right with disruption of the muscle bellies. There is extensive intramuscular haemorrhage within the muscle groups of the right lower leg. In the regions of both hips and proximal thighs there is evidence of shearing injury between skin and
underlying muscle.
Central Nervous System
Brain 1463 g. There is no extradural haemorrhage. There is fine film of subdural haemorrhage present over the Icft parietal cortex, artefact of removal of brain. No subarachnoid haemorrhage. ‘he vessels at the base of the brain show minimal atheroma and no evidence of aneurysm formation. No contusions noted. Coronal sections of the cerebral hemispheres are unremarkable. No intraparenchymal or intraventricular haemorrhage. No petechiac noted within parasagittal white matter or corpus callosum, Serial sections of the cerebellum unremarkable.
Transverse sections of the brainstem unremarkable. No petechiae noted.
Skin There was some subcutaneous haemorthage on the scalp in the left
frontotemporal region.
Examination of the face in the subculicular plane showed no evidence of haemorrhage. Examination of the upper limbs in the subcuticular plane showed haemorrhage on the posterior aspects of the left and right elbows, corresponding to the externally described injuries. Examination of the lower limbs in the subcutanéous plane showed extensive
subcutaneous haemorrhage involving both thighs and lower limbs.
Examination of the chest and abdomen in a subcutaneous plane showed
no evidence of subcutaneous haemorrhage.
Examination of the back including buttocks in the subcutaneous plane showed no evidence of haemorrhage on the back but there was patchy
haemorrhage over both buttocks.
Spinal cord and spinal column - Unremarkable.
« Special Investigations
Tissue taken for histopathological examination. (No whole organs retained).
Block designation as follows.
Uterus, right ovary. 9. Kidneys. 10. Splecn, pancreas. 11. Liver. 12. Anterior and lateral LV. 13. Posterior and septal LV. 14-18. Not taken. 21. Corpus callosum. 20. Pons. 23.
Midbrain. 24. Cerebellar vermis. 25. Left basal ganglia. 26. Left parictal cortex. 27.
Bone marrow.
Toxicology
Ethanol detected in blood and vitreous humour at 0.16 grams/100 mL.
Zolpidem detected in blood at 0.2 mg/L.
Quinine detected in blood at 1.4 mg/L.
Duloxetine detected in blood at 400 ng/mL.
Dextromethorphan detected in blood.
FSL specimens including oroanal genital swabs.
FSL photography.
Post mortem CT scan.
Tnitial phase of post mortem examination concluded 1510.
e Results a) Histology Lung: Sections show congestion.
Uterus: Sections show a low gland to stromal ratio within the endometrium.
Brain: Sections from pons, midbrain, cerebellar vermis, basal ganglia, corpus callosum and parietal cortex were unremarkable.
Heart: Sections from the left and right ventricle were unremarkable.
Liver: Sections show no evidence of chronic hepatitis.
The remaining sections exainined from ovary, pancreas, kidney, thyroid, pituitary, adrenal,
appendix, thymus, spleen and bone marrow were unremarkable.
1 (a)
Multiple Injuries
4,
Multiple cutaneous bruises and abrasions affecting predominantly the lower limbs with relative sparing of upper limbs and torso.
Fractures of proximal left femur and proximal and distal right tibia and fibula with virtual amputation of right foot at ankle with severing of blood vessels and fracture of
Icft great toe.
Probe patent foramen ovale.
Fine film left subdural haemorrhage (possible evisceration artefact).
No evidence of neck or anogenital trauma.
The cause of death in Phoebe Handsjuk is multiple injuries. She has sustained injuries to
the left and right lower limbs with subsequent significant blood loss.
The circumstances of Phoebe’s death are somewhat unusual. According to the police report she was located in the secured refuse room of an apartment block on St Kilda Road and was noted to have injuries to her lower limbs with extensive blood on the floor
in the vicinity. The circumstances suggested that she had climbed into a garbage chute
on the 12th floor some time after being seen on CCTV footage at 11:44:02 on 2 December 2010. Her body was discovered at 1914 on 2 December 2010. She had a past
history of depression, anxiety and an “alcohol problem”.
note there was no evidence of neck or ano genital trauma.
‘There was no evidence of any natural discase process that might have contributed to death.
Toxicological analysis detected ethanol at 0.16 grams/100 mL. Also detected were the
hypnotic zolpidem, quinine (a drug used for the treatment of muscle cramps and also
malaria), the antidepressant duloxetine and the antitussive dextromethorphan.
due.to described side-cffects, which include complex sleep related behaviours.
| 166 cm) to enter the chute if intent on doing so. ) With respect to the question as to whether any other party was involved in assisting her |
into the chute I make the following comments. If she was conscious and capable of
defending herself I would expect to see some form of defence type injuries to the upper ' limbs, and none were noted. Obviously if she was incapacitated in any way (for example
by the combined effects of the ethanol and prescribed medications) I am not in a position
to exclude the possibility of involvement of other parties.
been subject to the Institute’s technical review process.
In a supplementary report, Dr Lynch referred to photographs exhibit number 16(g) photographs 74 and 75, which show a number of circular and ovoid areas of bruising on
the right arm,'*
“8 ‘Ovoid? refers to an egg like shape,
e DrLynch gave further testimony about his findings at autopsy.149
274, Re Superficial bruising to right arm and neck and grazes to her lower back
‘The appearance of the bruises are those of recent injuries of non specific appearance,
that would be consistent with grip marks although certainly not specific for same’.
confidence level and with a plus or minus differential of 2.8 hours.
While there was some discolouration, a closer examination revealed that this was not caused by or the result of bruising. In regard to a suggestion in his report that there was some bruising found in the region of the neck, his further testimony was that he could not see bruising and what ever it was that it was consistent with some form of blunt trauma like that caused by going
down a chute rather than that caused by a throttling type injury.’
probable that this injury was an artefact of’ post mortem (as it could not be observed from the pre
4° Dr Lynch affirmed that he visited the scene on 7 December along with the system designer Mr Bone, so that he could assist in helping him to an understanding of how the compactor worked.
‘59 See exhibit 26(b).
51 Sce exhibit 16(h) photo 64, taken at the scene, which shows graze injuries and a good deal of foreign material, which attached itself to her back and the very much cleaner back shown in exhibit 1 4(g) photo 1, taken at the mortuary (prior ta autopsy). I note here that it appears that the dirt and other foreign material was washed off her back before the autopsy was commenced. See Dr Iynch’s description of this matcrial at transcript page 1077.
'? Sco exhibit 16(g) photographs 22 and 23.
'S See transcript page 1086.
‘4 Sco transcript page 1090.
'85 See transcript at page 1124.
279,
281,
post mortem CT scan), but agreed with Counsel that it might have been inflicted prior to her
entry into the chute.!*°
Re Severe injury to the right leg and lesser imjuries to the abdomen and thighs.
In reference to her injury to the right leg and the injury with the linear appearance, across both thighs, (transcript page 1092 and by reference to exhibit 21(c), a diagram of the chute and compactus. (See also exhibit 20(d), a further series of diagrams explaining the functionality of the compacter), Dr Lynch testified that this particular injury was caused by contact with a blunt contraption with a linear edge.'"7 A number of factors including both sharp and blunt components possibly contributed to the massive severance injury to her lower right leg, which
caused her severe blood loss.
Re Defensive injurics to fingers and nails.
His further finding was that she had not sustained any injury to her fingers or fingernails, and that he found no evidence of dirt on her fingernails and had not sustained defensive injuries. In response to Counsel for Natalic Handsjuk, Dr Lynch agreed however that he could not exclude the possibility that the ‘fairly minor injuries,’ to the back of her hand or clbows could be
defensive injuries sustained, before she entered the chute.'®
Re Movement of Phoebe in refuse chute.
Counsel Assisting: ‘Would you expect that someone who has fallen 11 storics (a drop of
)!59. would we expect to see more significant
approximatcly 30 meters damage to her internal organs, her pelvis, her chest cavity her liver her
musculoskeletal system?
Answer: ‘Not necessarily. I mean I consider her injuries, extensive. You know an unusual aspect would be that the fact that they are much more severe on the lower parts of her body and you know there are still injuries to her torso. And-the fact that there is no significant head, chest or abdominal
injuries is you know something that is observed’.
See transcript at page 1127-28 and response to Counsel for Antony Hampel, at transcript page 1167.
57 See the linear injury across both thighs at exhibit 16 (g) photograph 17.
See transcript page 1125. T note that Phoebe had trained extensively in kickboxing and martial arts. She was also was
physically fit, and was given to pressing her views in a forceful manner.
8 Sce transcript at page 1135.
Court:
Answer:
Court:
Answer:
‘Given that she has come down and suffered abrasion injuries on both arms and legs, is there a possibility that she controlled her movement
down the refuse tube?
Consider also that I’ve observed in previous cases of falling from a height, that the internal damage done on impact is usually very much more extensive with quite significant damage done to the skeletonal system, and quite oflen with a rupture of internal organs leading to the
filling of the pericardium with blood...
And having regard to the absence of such injuries, coupled with the injuries found on her arms, clbows and back, and given that the evidence suggests that following her fall she was still able to escape from the rubbish bin, into which she fell, and then crawl around the refuse room floor, J am wondering if it is appropriate to infer that this was something of a controlled fall,- where she was able to reduce the momentum of her fall by using her hands, arms and feet to apply force against the walls of
the chute, to control the fall? 1°
J mean... I would have no view on that... So in Ms Llandsjuks case the (injuries sustained to her lower limbs) reflect the way her body has
impacted ultimately as she exited the chute...
And you are not surprised by the absence of injuries to her internal
organs like the liver for instance?
Well if it was ruptured, I would say there has been some form of blunt force. There still has been force on her torso, It just hasn't manifested itself as internal structural damage. I don’t think it allows me to conclude that the was a fall from a lower height, or that part of the fall was controlled followed by an uncontrolled component. That’s possible, it might be possible but the pathology evidence doesn’t allow me to
prefer one or other of those scenarios.
18 Previous cases of falling from a height from my experience in investigating such deaths in [long Kong, suggest that significant injury to internal organs in the chest and abdomen, and to the skeletonal structure, were a common feature found in such matters, My reading of the following texts supports this pattern of injury, See Suicide by Fall from Height in Geneva, Switzerland, from 199] te 2000 J Forensic Science July 2003, Vol 48, No 4 and Frequency and Severity of injurics in Correlation with the Height of Fall. J Forensic Science May 2005, Vol 50, no 3. Sec also related discussion at exhibit 26 (f).
Counsel Assisting: Mr Bone, the system designer ... speculated that Phoebe’s hip became jammed in the area at the top of the compaction chamber such that her hip came into contact with the blade. And at the same time the ejection door, which we see at the base of the blade, opened such that Phoebe was (released) and fell into the bin. So both blades were open the ejection door and the compacting blade, which we see in diagram | exhibit 21 (c). Are you able to say whether her injurics are consistent with her
coming into contact with that part of the machinery?
Answer: So I would say that looking at the diagrams of the apparatus, the description of their being plenty of sources for blunt force, and some sort of possible source for blunt force, then the injuries I observed in Ms Handsjuk, would be consistent with her gaing through that
apparatus’! 6!
In further answer to questions from Counsel for Mrs Handsjuk, Dr Lynch could not say exactly how the bruises and abrasions were inflicted in the course of her movement through the chute, all he could say was that they were injuries which reflected some sort of blunt trauma and that they appeared to be recently inflicted.’ Dr Lynch also offered that the injuries sustained, were most likely to have been the result of her travelling down the chute feet first. Further there was nothing from his post mortem investigation, which allowed him to form a view as to when she
a : 163 had lapsed into‘a state of unconsciousness.
Dr Lynch was also questioned about the alignment of the chute and the effect of impact with the chute at an angle of 45 degrees. He would not have expected the injury to the right leg to have been caused by that impact. He was not able to say what injuries were sustained in the shaft itself only that the totality of injuries were consistent with the fall. He was not able to give a precise reconstruction of the fall. He considered that the 45 degree angle as opposed to a vertical fall, may have had a cushioning effect upon the fall, depending upon how her foot or
feet actually contacted the floor of the chute. He was unable to quantify the difference in levels
'S! See transcript pages 1096-1101 and later similar evidence in response to questions from Counsel for Mrs Handsjuk, at transcript page 1138-40 and at transcript page 1154.
‘None of the injuries I observed were unequivocal, typical examples of sharp force injury... The injuries to the hip are blunt force injuries... the injurics around the right lower leg have slightly cleancr edges which invites the possibility that there was some sharp force involved in producing those’. See transcript page 1143-44.
See transcript page 1134.
'8 Sco transcript page 1131.
| | | |
of force at impact, as between those possible sccnarios. He was also unable to determine the
effect of tube reinforcement (photo 66), upon the force of any impact.
Dr Lynch affirmed that he visited the scene on 7 December 2010 along wiih the systcm designer Mr Bone, so that he could assist by explaining the manner in which the compactor
worked.
Dr Lynch emphasized however that his opinions were based not on how the machinery worked, but instead upon the injuries likely to be sustained when Phoebe came into contact with any
particular part of the machine.
Dr Lynch then went on to cxplain that his view of the injuries was in a state of evolution and that he examined the chute without knowledge of her use of drugs and alcohol, or her level of physical agility and without knowledge as to the direction of the bin rotation. He also (correctly)
understood that she had exited into a secure refuse room.'“
Re Blood loss and its relationship to cause of death
Dr Lynch was further questioned about Phoebe’s blood loss, arising from the injury to her right leg. His evidence was that a person of her weight of 57 kgs might be expected to have approximately 7 litres of blood, and that if the injury was unattended, with no attempt to stop the bleeding, that sufficient blood loss to cause a loss of consciousness and subsequently death through hypovolemic shock, would be a ‘matter of minutes’, (and later), ‘five to ten minutes’,
following which, the person would ‘bleed out if not treated appropriately’. '©
Dr Lynch was also questioned about indications of signs of life, and stated that the ‘acid test’ was the finding of a pulse, and that you couldn’t say with absolute confidence that someone was deceased, without physically examining to establish that matter.“ Dr Lynch agreed that the
cause of death of Phoebe Handsjuk was exsanguination.!’
Associate Professor Dr Naren Gunja, Professor Olaf Drummer and Dr Morris Odell.
64 Exhibit 1 page 3 and transcript page 92. I also note that Ms Ozulup’s testimony was that she had used a key to unlock the refuse room door, when she entered the room that night and first found Phoebe.
'S See transcript from page 1104. I further note here that the cvidence suggests that the refuse room was not illuminated and was almost totally dark at the relevant time, and that the only illumination came from a splinter of light, which entered the room from the narrow opening between the under surface of the door, and the floor surface beneath.
'6 Sc transcript page 1133.
‘ST See transcript page 1183.
Associate Professor Dr Naren Gunja !™
289,
although another possible scenario, ‘would be overdose many hours prior to death’.
Professor Gunja offered the opinion that high doses of alcohol can act as a depressant to the central nervous system and can also lead to impaired balance and posture, as well as impaired
cognition and psycho motor performance as well as impaired judgement and reasoning.
‘BAC of 0.16% in the majority of individuals would cause significant sedation and impairment in cognitive and psychomotor function; most non-tolerant individuals would
find it difficult to maintain posture, and gait would be effected’)?
In regard to the use of zolpidem, Professor Gunja, stated that the drug was typically used for
insomnia and can produce sedation and coma,
‘an exaggeration of its intended effect which is somnolence. Since March 2007, there have been strong warnings on the prescription of zolpidem due to significant adverse reactions in some patients, Zolpidem has been associated with hallucinations, amnesia, increased suicidality, and parasomnias (complex sleep- related behaviours). These parasomnias usually take the form of automatisms that the patient is unable to remember the next morning upon awakening. Cases of sleep walking , sleep driving, sleep eating, sleep cleaning and various other sleep related behaviours have been reported, Although these events are uncommon, in a Korean study up to 3% of psychiatric outpatients reported anmesia or sleep walking from zolpidem, Zolpidem also induces imbalance and falls, with impairment continuing into the daytime well afterpatients take the hypnotic to go to sleep, This is observed particularly in women and the elderly, possibly due to reduced zolpidem metabolism and or heightened sensitivity
to its effects.”
Professor Gunja further advised that therapeutic levels of the drug are usually 0.1-0.2 mg/L.
We know that Phoebe who weighed just 57kg, was found to have a zolpidem level, of
0.2mpg/L, at post mortcm, and that this level suggests therapeutic use in the hours before death,
2171
'88 Associate Professor Gunja is a clinical and forensic toxicologist based al the Sydney Medical School, Westmead campus.
He testified via a video link from Sydney.
See exhibit 24 page 4, | note here that Phoebe’s use of alcohol over an extensive period would have rendcred her less
impaired, than someone who was non-tolerant.
" Thid page 5.
™ Ibid.
293,
294,
Concerning the use of Duloxetine, Professor Gunja offered the further opinion that the high
level found at post mortem does not inherently imply duloxetine overdose, or poisoning.!”
In regard to the circumstances of death, Professor Gunja referred to the difficulty in getting into the chute unaided. He also noted that in his experience death by suicide, by entry into a garbage chute was, extremely unusual if not uniquc. His further opinion was that none of the detected drug levels suggested that death resulted from poisoning. His further opinion was that given her history of alcohol usc her long time tolerance, was such that any impairment may be
reduced.
‘The BAC of 0.16% does not exclude the possibility, that Phoebe was physically capable
of entering the garbage chute unaided.”
Professor Gunja further reviewed. the likely interaction of Phoebe’s intake of zolpidem and alcohol, (cthanol). His view was that this combination would have synergestic effects causing drowsiness, altered perception and loss of balance. Her prior use of zolpidem would not have impacted her tolerance to it, as opposed to alcohol and benzodiazepines, which do induce
intolerance.
According to Professor Gunja there are two modalities in which ethanol and zolpidem could
have contributed to Phoebe’s death.
‘I. The drugs depressed her mood, judgement and perception — this may have promoted or exacerbated her suicidal thoughts, leading her to enter the garbage chute as a suicidal act.
would not have been physically capable of entering the garbage chute unassisted’!”*
‘In my opinion both ethanol and zolpidem had a contributory effect leading to the death of Phoebe Handsjuk. Both these drugs would have impaired her judgement, ability to think rationally and possibly exacerbate her suicidal ideation. They would also have impaired her psychomotor function and body balance. The issue of acute and long-term tolerance to ethanol makes definitive judgement on her ability to enter the garbage chute with a BAC of 0.16% difficult to ussess. However the added
synergistic effect of zolpidem with ethanol is likely to have significantly impaired,
? Thid page 6.
™ pid.
Ibid page 7.
though not entirely precluded, Phoebe’s ability to physically enter the chute
. 5 unassisted!”
Professor Olaf Drummer !”
298,
299,
Tn adding to the information provided by his ‘hot-tub’ colleagues, Professor Drummer
referred to the unusual sidc cffects patients taking zolpidem, sometimes endure.
‘While rare, patients taking zolpidem may develop adverse neuropsychiatric reactions , such as hallucinations /sensory distortion, amnesia, sleep walking (somnambulism),
and nocturnal eating’
Persons with no prior history of sleep walking had walked in their sleep after taking zolpidem.
Such behaviour occurs in about 5% of users. It included subjects who watched television, uscd
the telephone and walked to a friend’s house after use of the drug.'”
‘In another matter a 43 year old man presented with repeated sleep related injuries incurred during a violent nocturnal activity, which included frenzied running,
throwing punches and wielding knives, and also sleep driving’ !””
A summary of such reported episodes found at brief page 375-378, referred to by Professor
Drummer, is attached to this finding as attachment 1.
Professor Drummer further offered that,
‘An audit of calls to the Adverse Medicine Events Hotline (AME hotline) retrieved 915 calls between February and June 2007 where there was the suspected causal agent.
Sleepwalking, amnesia and other parasomnia related behaviours were features in approximately 85% of these. In the remaining 15%, adverse events occurred when the person was conscious and the effects raged from dependence, toxicity-related, idiosyncratic and those predictable from the drug’s pharmacology. Zolpidem was associated with triggering both isolated and repeated episodes, involving multiple different sleep-related behaviours. The audit revealed 13 deaths from zolpidem, as well as attempted murder (n=4); suicide attempt (n=12); suicidal ideation (a=14);
unintentional overdose (n=20), sleep driving (n=32); 60% resulting in motor vehicle
"5 Thid.
8 professor Olaf Drummer is head of the Department of Forensic Medicine at Monash University,
'™ See statement of Professor Drummer at exhibit 23.
"8 Ibid page3.
% Thid.
accident, sleep-eating (n=36): most causing weight gain, sleep-smoking (n=5); sleepdrinking of alcohol (n=9), disinhibited behaviour on an aeroplane (n=5); withdrawal anxiety and panic (n=34); psychotic behaviour and severe self-harm (n=7); hallucinations (n=19); anterograde amnesia (n=30), and addiction and dependence
(n=17).
in post marketing reports, zolpidem has been associated with a variety of bizarre sleep-related events — such as sleepwalking, sleep-eating and sleep-driving — with patients having no subsequent memory of the event. Sleep-related events have been reported with other hypnotics, but the pattern of reports with zolpidem has been interpreted by the TGA as signalling increased risk with this medicine. While these behaviours are considered rare, the incidence in uncertain. A casual link between zolpidem and these behaviours has not been established. Sleep-related events can occur with therapeutic doses of zolpidem in people without predisposing factors.
However, the risk is probably increased by alcohol, other CNS depressants, and high
doses of zolpidem.
In February 2008 the Therapeutic Goods Administration (TGA) placed a boxed warning on the product information of medicines containing zolpidem after receiving 1032 reports if adverse reactions of which 103 were related to sleep driving. The warning highlights potentially dangerous sleep-related behaviours that may be linked
to zolpidem use, which included,
a. Advice that zolpidem should not he taken with alcohol, and that caution is
needed with concurrent use of other CNS depressants; b. Recommendation to limit use to a maximum of 4 weeks;
c. Ifa sleep-related event occurs during use of zolpidem (or another hypnotic), stop
the medicine to avoid potential harms to the patient and the community; d. Non-drug therapies are recommended as initial treatment for insomnia,
e. Reserve short-acting benzodiazepines (e.g. temazepam), zolpidem, or zopiclone far
short-term severe insomnia, and for intermittent use in chronic severe insomnia
unresponsive to non-drug therapies’. 180
18 Soe exhibit 23 pages 3 and 4,
Professor Drummer also pointed out that there was no information as to how Phoebe reacted to zolpidem usually, and that it was likely that the alcohol level (over 0.15%), ‘will dominate
her drug-induced behaviours’ .
‘Alcohol over 0.15% will not only depress the central nervous system but also cause disinhibition, and reduce the ability of the individual to make informed and rational
decisions...
The presence of zolpidem will only worsen any adverse effects associated with excessive
alcohol, in the same way as the combined use of alcohol and benzodiazepines...
As to her ability to climb through a small waste chute, I can only comment that whatever her motive the combined effects of the drugs is likely to have adversely affected her ability to make clear and rational decisions... Death occurs not only from the associated high risk taking behaviours but also from the inability to save themselves once potentially exposed to a
potentially life threatening event’.!*!
Dr Morris Odell!
w a) Lae)
Dr Odell was asked for an opinion concerning the effect of alcohol and drugs upon the death
of Phoebe Handsjuk.
In response, he offered that he did not ever physically examine her and that he understood she was found deccased at 6.50 pm on 2 December 2010, having fallen 12 floors in the refuse
chute of her apartment building.
At post mortem toxicology samples returned the following analysis.
1 Alcohol 0.16% in blood and fluid from the cye.
2 Zolpidem (Stillnox) 0.2 mg/L in blood.
3 Quinine 1.4 mg/L in blood.
4 Duloxetine 400 ng/ml 5 Dextromethorphan — detected in blood.
In regard to zolpidem, Dr Odell stated that it was a short acting sedative, which is used as a sleeping tablet. It is quick acting, dispensed on prescription only in 10 mg tablets, and that the
usual dose is one per night. It is quick acting with a short duration of action of only a few
18}
Ibid page 4 and 5,
'® Dr Morris O’Dell is a forensic physician at the Victorian Institute of Forensic Medicine, His field of speciality includes the effect of alcohol and drugs and the assessment of persons affected by both.
hours, ‘and no residual sedation or hangover effect the next day...As with many sedatives.
there is an imprecise relationship between blood levels and effects. In this case the blood level of the drug was within the therapeutic range where an effect would be expected.
Zolpidem has a blood half-life of 2-5 hours. The manufactures warning for Zolpidem warns against use with alcohol and that caution is needed with other depressant drugs. Limit use to
four weeks maximum under close medical supervision. 1
‘A study of sleep related behaviours also identified the possibility of complex sleep related behaviours occurring during sleep with no recollection by the person after waking. The activities described included eating, sleepwalking with object manipulation, conversations,
driving, sex and shopping’.'**
Dr Odell further opined that it was not possible to tell the precise effect that her intake of alcohol and zoplidem would have had although it would be expected that the degree of
intoxication would have been exaggerated by the zoplidem.
The combination of these two drugs, ‘has been associated with complex activities that are
either _classed_as somnambulism (technically sleepwalking but which includes the other
activities listed above) where the person is completely asleep and unaware_of and
unresponsive to external stimuli, or confused sedated behaviour which can be considered as
seyere intoxication.
In either of these states the possibility cannot be excluded, that she climbed into the garhage
chute without conscious awareness of the act, or specific intent to do it.’ '*
The underlining is mine.
Concurrent evidence from all three expert witnesses.
307,
In oral examination of Dr Odcll and Professors Gunja and Drummer, (all heard together as part of a ‘hot-tub’ evidentiary process), the group offered that they were unable to determine when Phoebe had ingested the substances found within her system or the quantity so
consumed,
It was also the case that toxicological examination did not indicate that she had taken a
massive quantity of the pills concerned.'®° Her level of zolpidem was also consistent with the
'® See exhibit 22 at page 3.
Thid.
185,
Ibid page 4.
386 Soc transcript page 1003.
310,
possibility that she may have taken say one tablet at night before retiring. '*? Depending upon the number of tablets taken the zolpidem level is also likely to reflect that she had taken the
drug several hours before, rather than up to 24 hours before her death,!®
The further collective evidence was that the zolpidem has a relatively short period during which, sleep is induced, but a relatively longer period in which, it continues to effect posture, balance and the ability to perform tasks. Redistribution was not likely to have been effected by
vigorous activity.
The three witnesses were shown Phoebe’s movements as recorded on CCTV, at between
11.44 and 11.50 am, on Thursday 2 December 2010.
Dr Odell’s opinion was that the evidence of her movement at that time was quite normal, ‘for what she is doing. She doesn’t look like she can find what she is looking for (in her bag) but not in a disorganised way, ...I don’t think there is anything there which would indicate that
she is intoxicated. ?°?
Professor Gunja’s further opinion was that to achieve the levels of zolpidem and alcohol found at post mortem, that Phoebe would have had to ingest both substances after her return to the apartment at 11.50 am, this having regard to his view that the CCTV record of her entry
into the building at that time, did not reveal evidence of her intoxication.’
The group also offered that the use of the antidepressant Duloxetine (Cymbolta), to a
therapeutic level, would not have impacted on function.””!
Professors Gunja and Drummer further offered that the cases of bizarre bchaviour from zolpidem, where individuals did things unknowingly, (parasomnia events) were in the majority of cases, concerned with behaviours that they would normally do on a daily basis. ie.
sleep cleaning, eating , driving ctc. Additionally however, there were reports of people doing things they would not normally have done.’”* Professor Drummer’s further view was that he had seen cases both in the Coroners Court and in our Criminal Courts, where the impact of zolpidem had arisen and that it was sometimes difficult to establish the existence or non-
existence of intent. His view was that where parasomnia had arisen in conjunction with other
87 See statements from Professors Drummer and Gunja, at transcript pages 1005-07,
"8 Sec transcript at pages 1010-11.
® See transcript page 1017, which opinion was adopted by Professor Gunja, also at transcript page 1017.
'® See transcript page 1060.
See transcript page 1018 and 1025-29.
192,
See transcript page 1019-21.
316,
319,
than day to day activity, and that in the end il was for the Court to decide what was most
likely.
In regard to what to look out for when seeking to establish whether a person was in an, ‘automatic state’, during the course of an event, Dr Odell stated that sometimes security video
can assist and certainly examination by a trained professional will assist.
‘The state there in is a bit like dreaming. Sometimes the person dreams of things they
would be doing in their normal life but in_a distorted fashion... this kind of behaviour
under these drugs brings dreams to life if you like so people don’t just experience
dreams in their mind but go out and act on them.”
The underlining is mine.
The group was then questioned about whether one could have an adverse reaction to zolpidem after not having had a reaction to an earlier use. All agreed that there could be an adverse
reaction occurring for the first time, in a second or future use of the drug.
As earlier, Professor Drummer further offered that the use of alcohol in conjunction with zolpidem would amplify the adverse effects of the zolpidem. This would cause an increase in sedation, and decrease the ability to think clearly as well as effect balance and posture. ' Professor Drummer also spoke of the disinhibition effect that alcohol and zolpidem can have on emotions and behaviours, reducing the ability to make rationally considered decisions
during the period of intoxication.!”*
All witnesses agreed that the intoxication levels would not have prevented Phoebe from actually forming an intention to commit suicide. Professor Drummer further offered that her clinical state, ‘could be asleep, to being conscious and being in a disordered state and doing
things...such as what we have seen (in this case)’.'*°
Dr Odell further testified that the fact that she was intoxicated to the extent described above would have made her efforts to enter the chute more difficult, but this did not exclude the possibility that she could have climbed into the chute, without aid. Similarly Dr Odell and Professor Drummer offered that her intoxication would make any attempt to climb down the chute (and control herself in that environment), very difficult to achieve. In answer to a
question from Counsel for Mrs Handsjuk, the group further stated that based upon the
85 See transcript at page 1023.
' See Professors Drummer and Gunja at transcript page 1024,
85 See transcript page 1030.
See transcript page 1031-32.
320,
materials they were provided with prior to the hearing, they were unable to offer additional
comment on whether she had put herself into the chute or had been placed into the chute.'?”
Counsel assisting the Coroner, then took the group to the issue of the articles about zolpidem found in the brief and the United States FDA requirement that the Zolpidem recommended dosage level for women, be reduced by 50%. All members of the group agreed with the opinion of Professor Gunja that the FDA decision was based on data, which showed that women were not able to clear zolpidem as well as men, because of their altered metabolism,
and that women were more prone to the sedating effects of the drug compared to men.
‘So with the differential agenda susceptibility, I would agree that this should happen in Australia, worldwide really. Already there is a recommendation that elderly patients
have their doses reduced by 50%, but that should be for women of all ages’.'™*
Counsel then referred to the Australian Theraputic Goods Administration, decision (February
effects of the drug.”
The group’s view was that Stilnox was a sleeping tablet and not a drug of addiction, and accordingly that it should properly remain a schedule 4 drug, ‘where if is at the moment’. Hf it were to become a schedule 8 drug, we would see its limited availability so a Dr would need a
permit to issuc it.
Instead, (in their collective view), what was needed were warnings to the profession and to the public so as to limit its prescription over a long period of time, and to reduce its dosage to
certain pcople.
According to Professor Drummer warnings to doctors should also be issued about the need to closely monitor patients on zolpidem, in conjuction with any other prescription medication.
Professor Gunja also informed that in the US, users of Sanofi sleeping pills, (zolpidem) were specifically cautioned against taking zolpidem as a primary therapy for depression or psychosis. In Australia we know that at the present time the TGA cautions against taking the drug with alcohol or with other CNS depressant drugs and stipulates a maximum limitation of
use, to 4 weeks, ‘under close medical supervision’?™
See transcript page 1061.
See transcript at page 1041.
1 See inquest brief 912. The minutes of a National Drugs and Poisons Schedule committee where the committee declined to reschedule zolpidem from a schedule 3, to a schedule 8 drug.
200 Seg transcript at page 1048,
Findings
327,
329,
330,
332,
Having directed my self in respect of the law on the standard of proof, and the law on circumstantial evidence and specifically as to when it is open to draw an inference as proof of
a fact, or facts in issue, I make the following findings.
Through parts of the last several months of her life, Phoebe was sometimes thought disordered, and in a low mood, J am further satisfied that during this period she wished to end.
her relationship with Antony. To this end, they separated on at least four occasions, but in
each instance Phoebe returned to him, at his urging.
1 further find that throughout their relationship Phoebe suffered from depression, for which
illness she was receiving treatment, from her GP.
It is also the case that over the last few months, Phoebe lived in a world where her life was increasingly chaotic, and that she tumbled between instances of elevated mood and high energy, and then down to the excessive use of alcohol, and drug taking, which intake often in combination, led to her lowered mood and to a crippling, lowered self esteem and self loathing.
This latter mindset usually arose in the context of her failure to meet behaviour standards set by Antony, who was approximately 19 years her senior and with whom she appears to have
had a deeply troubled relationship.
It is also true as explained by Antony, and confirmed by Russell Marriott and Ben Silver, (and not disputed by her family), that Phoebe was sometimes very outspoken and difficult to deal with, I further observe that there was no history of physical violence between Phoebe and Antony and that her mother, who had been kept informed by Phoebe concerning certain details of her life with Antony, appears to have supported the relationship.
I further note that Antony had tried to be supportive of Phoebe and had on occasion, been generous to her friends.”"' It is additionally the case that during the last week of her life, Phoebe’s behaviour caused concern to a number of those who were in contact with her, and that over this period it can be seen that Antony made a concerted effort to try to protect her
from the possibility of harm.
I further find that Phoebe was often requested to accompany Antony, an events manager, to his work related social events. She was not comfortable attending such occasions, or indeed
attending any event, which included persons other than members of her family, or her close
*) Sce statement of Ben Silver at exhibit 42 page 155.
333,
335,
friends. She frequently resorted to alcohol to help deal with her lack of confidence and the anxiety she felt in such situations.*” After such incidents and the arguments, which followed, she would sometimes continue to drink and finally then scck rest. This rest was sometimes
aided by the use of un-prescribed sleeping medication.”
Thereafter and inevitably she would wake and spiral into a low mood period, during which she would blame herself fearing that she had misbchaved and had agdin failed to live up to
Antony’s expectations.
1 further note that over this period her attendance at work became more and more irregular.
It is also the case that Phoebe informed her psychologist, whom she saw regularly over the last 12 months of her life, of her deep unease over the fact that she belicved she effectively had no prospects and no financial resources. This matter was a source of ongoing anxiety for her as she increasingly recognised her financial dependence on Antony, while feeling
personally insecure and uncomfortable about the future of their relationship.
In her last few days, she also came to feel that there was no one left to whom she could turn. T am satisfied however that throughout this period she was (in fact) well supported by her family, but finally did not feel that she could unload her troubles again on them at this time, this perhaps because she was embarrassed by her immediate past history of break-ups with
Antony, followed soon after by their unsuccessful attempts to reconcile.”
I further find that it was in these circumstances, that on Tuesday afternoon, 30 November 2010, Phoebe called her psychologist and told her that she felt ‘unsafe’ and sought her help. 1
deal with this issue below under the heading Comments.
Thursday 2 December_2010
On the morning of Thursday December 2, 2010, I find that Phoebe got up and lefi the
Balencia building at 11.43 am, with their dog Yoshi, in compliance with a fire alarm exercise.
2 Dhoebe was more at ease when she was away from the city, in places like Mallacoota. She also particularly enjoyed visits to his family’s country home.
7° According ta Antony, Phocbc had used zolpidem on at least one such earlier occasion, Immovane, a sedative, had also been previously uscd. Sec transcript at page 1398.
24 See her discussion on this subject as reported in the statement of Ben Silver, at exhibit 42 page 158,
~~ Page 73 of 83
w w Oo
341,
342,
344,
She returned at 11.50 am. At the time, she can be seen on CCTV moving in a manner, which the expert evidence suggests, does not establish that she was effected by the intake of alcohol,
or zolpidem?
Zolpidem, sold in Australia as the sleeping pill Stilnox, is an hypnotic drug with similar pharmacology to benzodazepines. As explained by Professor Drummer, Associate Professor Gunja and Dr O’Dell there have been unusual reactions associated with the use of the drug particularly when intake is associated with the use of alcohol, (which use in combination, is
strongly contra indicated). Such use exaggerates both Zolpidems sedative and amnesic effects.
Some instances of the unusual reactions believed to be caused by Zulpidem use, are described in Attachment | to this finding and have been likened to sleepwalking. This activity occurs in a state of unconsciousness, while the parts of the brain that are concerned with motor control,
remain active.
At some point on 2, December 2010, we know that Phoebe commenced to drink an alcoholic substance, probably vodka. This she consumed in addition to her intake of an uncertain quantity of the zolpidem, which remained in her system to a therapeutic level at the time of her death. As above, her blood alcohol level at post mortem was measured at 0.16%. I further note here Professor Ganja’s opinion, that having regard to the toxicology results and his observations of her re entering the building, that at least the major part of her intake of alcohol
and zolpidem is likely to have occurred after her return to the apartment.
During the course of the day it is known that she used her computer and that she checked incoming email. She also listened to music and lit candles. Tt seems probable that she also spent some time sleeping. While her computer use may well have extended well into the
afternoon, it is certainly the case that she used it up until 12.02 pm.
At some stage, she dropped and broke a glass. At a later point she attempted to clean up the glass fragments and may have placed them into a plastic rubbish bag, while cutting her self in
the process.
At some later point shoeless and without her bag and keys, she left the apartment (and her dog
and the lit candles), and went to the refuse room on the same floor, where a small portion of
See the evidence of Dr O’ Dell and Professor Gunja, referred to above. My own sense of the CC'l'V was that it did might
have indicated a certain level of intoxication in Phocbe, and in these circumstances, | do not exclude as a possibility that to some extent, Phocbe was alcohol/drug, affected at this time.
Stifnox is the product name of the medication prescribed to Antony. Zolpidem is the drug name of the medication, trade named Stifnox.
346:
blood from her earlier cut was subsequently found. She is likely to have put a bag of rubbish
into the chute at this time.
Thereatter, in a poor condition arising from her consumption of alcohol and zolpidem, at least the latter of which was unwittingly made available to her by Antony, I find thal Phoebe climbed into the chute with her bottom initially seated on the inside surface of the refuse entry
door.
At the time I find that her mental state caused by her earlier intake was the same as the stale described above by Dr O’Dell, (‘similar to that of sleep-walking’), i.e. an unconscious state with a level of motor control in place, or at the very least, that she was deeply confused and quite unable to think in a rational manner.
Phoebe’s long-term enthusiasm for climbing, and penchant for undertaking physically
challenging activity was a factor in this event°°
She then levered herself into the chute while still facing away from the entry door and commenced to move down the chute cylinder, this in the initial stages at least, by pressing her extremities, and her bottom and back against opposite walls of the chute, thereby controlling
herself in descent.
As set oul above the precise effect that the combination of zolpidem and alcohol had upon her cannot be established to a great degree of certainty. I am satisfied however that her use of these substances in combination, did in fact impact upon her mental state in a significant way, and directly led to her entry into the chute. I further find my self satisfied that absent the effect of this intake that Phoebe would not have determined to take on the risk of severe injury or death, which risk was implicit in her climbing into the chute. I so conclude having particular regard to the fact that these events took place on the eve of the family celebralion of her brother Nick’s 18" birthday. See the evidence of Russell Marriott on this matter as set out above and the similar observations of Lorne Campbell at exhibit 7 page 7, (where J note that it is also suggested that Phoebe and her mother whom she had not seen for some eight weeks, arranged, in a skype call on Sunday November 28, to spend the following Friday together,
preparing for thal evening’s party). Her history of occasional bouts of suicidal ideation,
288 See the evidence of Professor’s Gunja and Drummer, and Dr O*Dell as to relevant considerations in determining the existence of ‘automatic’ behavior. See the evidence of Antony Hampel, Jeanette Campbell and Brendan Hession, concerning her history with reference to climbing and physical exertion. Her long-term training in martial arts and kickboxing, and participation in cliff face and other forms of recreational climbing, as testified to by her grandfather, is also noted, (See his evidence at exhibit 7 page 1, and transcript page 361), Her wrestling with, and her later playing ‘chicken’ with moving cars as described by Ben Silver, may also be relevant.
without an accompanying plan of actually undertaking suicide, and the availability of other
options is also relevant.
aid of, any other person.
e [tis clear that at the time of the matters under examination, Phoebe was physically fil and very strong. She exercised regularly and aggressively, in part because she had always enjoyed physical exercise, and more recently because she saw physical exertion as a means, which would assist her efforts to control her illness, a result she desperately wished to achieve. I also note that she was very agile and at 166 cm and 57 kg, was small enough to pass into the refuse cylinder, (made for the most part of pressed steel and 530 mm in diameter), and through the refuse cylinder entrance, 7%
e Tt is further relevant that her body, like all bodies, was irregular in shape.
e As above I note here that Phoebe was last seen alive at 11.50 am and was found deceased by Ms Ozulup, between 7.06 and 7.09 pm. It is also the case that the evidence from the card swipe data, and the limited available CCTV evidence, does not suggest that any one entered the lift to the 12" floor, without plausible cause, or otherwise accessed the 12 floor until Antony’s arrival home shortly after 6.05 pm. In so finding I note that there is no evidence to suggest that any of the four management keys, (which were not programined to register a swipe destination), were borrowed or stolen, to achieve this purpose.
Similarly the evidence concerning ‘buzz ups’ (ie. residents specifically permitting entrance to a visitor), between 12 noon and 7.09 pm. did not record that any visilor had
entered the 12" floor in this manner.?”
208 There is no evidence that the injuries sustained in her fall caused major skeletonal structure damage, which if it had occurred may (or may not) have explained why her height at autopsy was less than her height in life, In the circumstances, J accept the autopsy evidence concerning Phoebe’s height.
20° See transcript page 106-07. Evidence from Mr Giamartio was that his understanding was that all such ‘buzz ups’ would normally be recorded. A test conducted in the course of the inquest also established that such ‘buzz ups’ would be recorded to the floor destination, but not to the apartment number, See also the discussion concerning the explained use of the building lift on 2 December, by Mr Getch at exhibit 16, Mr Theodore at exhibit 38 and evidence concerning the card used by Mr Sari at footnote 17 above. :
Tn so finding I record that the manner in which Antony’s family were able to access his apartment later that evening was not investigated and remains unexplained. I also note that there were contractors accessing different sites within the building during this time and that their cards were programmed to allow access the whole of the building.
I further observe that the injuries both external and internal, sustained in Phocbe’s
movement over some 30 meters towards the ground floor, ie. before reaching the compactor, were not typical of those she might reasonably be expected to have suffered if she had deliberately gone into free fall, or if having earlier been rendered disabled or unconscious by another, she was then released from the 12" floor and caused to fall in
freefall, down the chute.
As above I note that there were virtually no internal injurics or bleeding, that were of the severity reasonably to be expected, if she had gone into a free fall, and had then landed on a rigid or near rigid (reinforced) surface. Even allowing for the 45-degree angle change and the possible cushioning effect of this direction change (at the bottom of the chute), the absence of such internal injury persuades me instead that, at he very least, Phoebe was able to and did manage to exercise at least some control over a significant part of her fall.?'°
It is also the case that there was no evidence of skin stripping, and relatively few external
collision/limb trauma type injuries, to any part of her body. Again, her righi lower leg
apart and left big toe apart,- her bottom, her upper thighs, her shoulders and her head for example, sustained only superficial injuries in the context of what might have been expected from contact with the chute walls if she had instead travelled down the chute,
with free fall momentum.
T further conclude that if shc had got into the chute cylinder involuntarily, having been placed there by an assailant, while unconscious or otherwise defenseless, or otherwise if she had voluntarily entered intending to cause her own death by free-fall, and then gone into free-fall, that there would have been major trauma resulting in internal injuries as
discussed above, as well as external injuries to her torso head and limbs.
These later injuries being sustained as her momentum increased and as her various irregularly shaped body parts were caused through collision to come into sometimes
violent contact with the walls of the cylinder, and also as they passed through the cylinder
] further note that there was no evidence to suggest that any person had a motive to cause the death of Phoebe, or to join ina conspiracy to cause her death, or thal any such conspiracy could or would be planned and carried out in such an unlikely, and high risk manner. The further cvidence that Antony made an unexplained return call toa Western Australian telephone number, at 6.24 pm on December 2 is of neutral valuc to this consideration.
See discussion with Dr Lynch, and academic writings referred to above at footnote 160. I note here that for obvious reason, these writings do nol purport to refer to instances of a fall from a height, through a multi-floor refuse disposal.
and over partly vacant spaces on the chute wall, into which, refuse at lower floor levels,
would normally be placed.?!!
e 1 find then that the absence of major trauma to her internal organs, and (her right leg and left big toe apart), the finding of relatively superficial injuries to her torso, limbs and head, coupled with the fact that we now know that she was alive and conscious at the ground floor when she manoeuvred herself out of the bin, (and along the refuse room floor), all combine to establish to my satisfaction that her passage down the chute was at least in
significant part, a controlled passage.
353, It follows that I conclude that her descent was not one caused by either the fact that she had earlier been placed in the chute while unconscious, (but not in an automatic statc), or otherwise rendered unable to exercise control over her decent by an assailant.” T am similarly satisfied that she did not consciously determine to undertake a descent by free fall, with the
intention of bringing about her own death,”
354, As above then and having regard to all of the evidence, I conclude that in an zolpidem/ alcohol induced sleep walking (automatic) like state, or while decply confused and disorientated, Phoebe entered the chute and began to climb down towards the ground floor,
this without any awareness of the dangers implicit in this behaviour.
parts of her body, as well as a fractured left big toe.
have attached to this finding as attachment 2.
accept from the cvidence of Dr Lynch, and also from the inquiries initiated by Phoebc’s grandfather, Mr Lorne Campbell and his event reconstruction, that Phoebe entered the chute fect first. Concerning her alignment within the chute, I also find that she commenced her descent having first sat on the back of the entrance door, (facing away from the entrance). This latter information follows from the evidence that both young women who commenced to enter the chute in the fall reconstruction, did so with difficulty and could not turn around having first manoeuvred their lower bodies into the chute entrance. It also follows from the position of the indentations at the lower floor refuse entry points (see again Attachment 2 and transcript pages 935-36), and the alignment of the angled section of chute, coupled with the almost complete absence of facial injuries, which injuries, may have been expected if Phoebe she had gone down the chute (in darkness), with her face positioned facing out, (which would have caused her face to come into contact with both the indented edges at the refuse entry points, and jnally with the underside of the angled section of chute).
Similarly, in regard to external injury and the possibility of frec fall momentum, I am satisfied that her feet first/face in alignment, coupled with the receding refuse entry indentations, at cach lower floor as.discussed by Mr Bone at transcript page 897 and at 935-36, would have caused substantial external injury if she had passed these points in free fall momentum. T am also satisfied that Phoebe would have also suffered an injury to the back of her head, (if she had been in free fall), when she cntcred the 45-degrec (reinforced) angle chute scction below. As we know there was no evidence from the post mortem examination suggesting the existence of extemal injury of this kind.
I further note from the evidence of Dr Lynch, that the absence of apparently defensive injuries, is consistent with this conclusion.
213 1 am also mindful of the fact that if Phocbe had actually determined to end her life, and then planned how she would do so, that she might easily have set out to achieve her objective by sleeping tablet overdosc, which I note would secm a far less confronting possibility than getting into a 12" floor refuse disposal.
~ Page 78 of 83
357,
362,
Thereafter she further suffered a catastrophic near severance injury to her lower right lcg, this injury sustained as she passed into and through the refuse system compactor; situated at the
bottom of the chute.
The course of her blood spill from this severance injury, was examined in detail during the course of my imquiry and was the subject of expert evidence from both Pathologist Dr Mathew
Lynch and Forensic Officer Louise Brown.
Further, the internal workings of the machine’s compactor located at the bottom of the chute, and the computer driven movement of the steel blade within, were also examined in detail.
This examination was carried out with the considerable assistance of the system designer, Mr
Neil Bone.
As a result, it is not now in dispute thal Phoebe’s blood loss from her right leg injury, (sustained as she passed through the compactor), was the major factor contributing to her death. It is also not in dispute, that Phoebe initially fell into a near-empty rubbish bin, having just sustained that injury. That is to say that following the infliction of this injury, Phoebe was not constrained within the compacting device, and was immediately released feet first into a rubbish bin, (the bin held within a rotating whecl of similar sized bins), which was situated
under the chute opening.
Thereafter, I find that despite her pain and with circulatory shock beginning to take effect,
that she managed to tip the rubbish bin over while thinking of survival and seeking to escape.
Having fallcn to the floor and in almost total darkness, I find that Phoebe then commenced to
crawl in a clockwise direction, around the floor of the refusc room.
I note here that the initial suspicion of investigators was that Phoebe had in fact died more or less immediately as a result of injuries sustained in her fall, and had then been dragged by the bin rotation device towards the position near the door, in which she was found. The further belief was that this had occurred in accord with the directional movement of the rotation device in a clockwise direction, which allowed for the scheduled movement of bins towards
and past the machine refuse discharge chute.
However, the fact that the bin rotation device is now known to have rotated in an anticlockwise direction,‘ coupled with the blood spatter cvidence given by forensic analyst,
Louise Brown, which establishes to my satisfaction that Phoebe herself in fact crawled in a
2d
See the second statement of Mr Bone at exhibit 20(a).
clockwise direction, (coupled with the evidence of her extensive blood loss in that place), all
leads me to the different conclusion, referred to above.
refuse room door.
1 (a) Exsanguination
(b) Injuries sustained while attempting to climb from a height, in the setting of alcohol and
zolpidem consumption.
Comments
L During ihe course of my investigation into this matter, much criticism has been levelled at
Victoria Police by Phoebe’s grandfather, former officer, Lorne Campbell.
This criticism has focused on allegations that,
. a) Victoria Police failed to seek CCTV foolage of the entrance, lift and foyer area, which footage had the potential to allow for the identification of any person or persons who
may have been involved in perpetrating an assault upon Phoebe.
. b) Victoria Police failed to seize telephones and the two computers, from Antony’s
apartment on the night of 2 December 2010.
. c} Victoria Police members at the crime scene ground floor refuse room, wrongly refused to allow an Ambulance Officer, to examine Phoebe to determine if she was still
alive.
In regard to criticisms a) and b) above I observe that in the circumstances as they presented al
thai time, the collection of the IMac Computer (subsequently analysed by a Victoria Police IT expert, with neutral result), should have occurred on the evening of 2 December 2010, this having regard 1o Antony’s explanation that Phoebe appeared to have used the computer during that afternoon, as well as to the existence of a suspected blood droplet on the computer mouse. I further find that this did not occur, because officers considered that the evidence was suggestive
of a suicide, and that the privacy rights of Antony Hampel did not justify the seizure of his
computer at that time. I also note that Phoebe’s iPhone was being repaired at that time, and was
obtained by Victoria Police some five days later.
Concerning the CCTV footage this should also have been interrogated and I find that this ultimately did not occur because of a failure in communication between the Apartment manager Mr Giamarrio, unidentified members of the Purana squad and the senior Homicide squad
Detective who bricfly took charge of the investigation.
In regard to criticism c), I am further satisfied that an ambulance officer should have immediately been given: access to Phoebe on arrival at the scene. I also note however for the reasons set out in discussion of the evidence of Dr Lynch above that it is clear that Phoebe was deceased by the time the ambulance officers arrived at the scene.*"" There is also no doubt, in my view that Victoria Police will continue to prioritize the preservation of life, above the perceived possibility of damage to the integrity of a crime scene, in determining how to proceed
in any particular instance.
It is also appropriate to record that these omissions have not caused a lacuna like difficulty in the circumstances of this investigation, this having particular regard to the swipe card evidence and the additional circumstantial evidence discussed above, which together with the rest of the evidence has led to a comfortable degree of certainty concerning the findings and conclusions,
here set out.
Concerning the psychologist Ms Young, I further observe that her efforts made to provide protection to Phoebe, were the subject of her own self-criticism, this especially concerning her initial failure to set up an emergency management plan and later on November 30, to notify a CAT team of her concerns for Phoebe’s wellbeing. I note her comments on these issues and
have nothing to add.
Finally from the evidence of Professors Drummer and Gunja, and Dr Morris set out above, I am
additionally satisficd that there is a need for the Australian Theraputic Goods Administration (ATGA), to review the conditions under which Stilnox is permitted to be prescribed and sold in
Australia.
Recommendations
Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s) connected with the death:
See paragraphs 197-98 above.
« Specifically, T recommend to the ATGA, that in accord with current United States FDA requircments, that the dosage of Stilnox, recommended for administration to female patients be reduced by 50%, (which may be increased in accordance with individual patient requirements). I also recommend that the RACGP examine existing prescribing practises in this area and provide
practitioners with advice concerning the dangers in over prescription of this drug.
e | further recommend that henceforward only 5 mg tablets, (rather than the 5 and 10 mg tablets cutrently in use), become the tablet size permitted to be supplicd to all users in Australia. To claborate, that one tablet size only, should be made available to both male and female patients,
(and that a 10 mg tablet, should not continue to be offered). 7!
Conclusion
T thank the witnesses and interested parties together with Counsel assisting, Ms Siemensma, my Solicitor, Ms Gebert, the Informant Detective Constable Payne, and indeed all Counsel and Solicitors for their assistance in the conduct of this investigation. I also thank the witnesses for their evidence, and those others who made submissions, I also wish to thank the Forensic Scrviccs Division, Victoria Police, for responding to my request and making an IT expert available, to analyse the computer used by Phoebe before her death, this in an attempt to collect all possibly relevant cvidence concerning her state
of mind at that time.
Finally, it is clear that during early stages of this investigation certain assumptions were made, based upon the evidence then available, and that as a result parties became hardened in their views as to what had happened to Phoebe. We now know that several of the assumptions referred to, particularly as they
related to the functioning of the refuse compactor, have been shown to be incorrect.
Tt is also the case that the early-established circumstances of this matter were of such an unusual nature that a considerable public interest in the investigation was provoked, Additional publicity then given to these matters, led to further speculation concerning how Phocbe diced and unhelpfully, as to who might
have been responsible.
It is my hope that notwithstanding the additional pressures on Phoehe’s loved ones so created, that this
group will in time feel able to focus upon their own personal interactions and memories of her life and
36 Appropriate other reductions should continue to be mandated in respect of the elderly and the sick, all of which should be included in the manufacturer’s product advice, together with other presently cxisling product information.
This recommendation is made having particular regard to anecdotal evidence concerning the frequency of the shared use of slecping tablet medication, and of the need to seek to reduce ihe possibility that such behaviour, undesirable as it is, will lead to an inadvertent overdose by either a female, or an elderly or ill recipient.
contribution, which memories (rather than what is recorded above), should define who she was and what
her life meant.
T direct that a copy of this finding be provided to the following: Ms Natalie Handsjuk
Dr Leonard Handsjuk
Mr Antony Hampel
Ms Jeanette Campbell
Mr Lorne Campbell
Ms Joanna Young
Professor Drummer
Associate Professor Gunja
Dr O’Dell
Dr Lynch
The Chief Executive of the Australian Therapeutic Drugs Administration The Chief Executive of Sanofi-Aventis Pharmaccuticals, Australia Pty Ltd The Chief Executive of the Australian Psychology Association
‘The Commissioner for Police, in the State of Victoria
The Manager, Coroners Court Prevention Unit, Attention Mary Hyland
“Signature:
; oo
December 10, 2014.
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LEVEL 23 3600 mm
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LEVEL 22 3100 mm
LEVELS 16 — 20 3000 mm
LEVELS 8 - 14 2850 mm
LEVELS 7,15,21 3200 mm
LEVELS 2 - 6 2940 mm
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ECOPACK 100 COMPACTOR WiTH 5 X 240 LT ROTOFEED
LEVEL 1 3600 mm
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AND SERVICE OF WASTE DISPOSAL AND _| ENGINEERING : RECYCLING EQUIPMENT No: | DATE REVISION INT. 21 CAPITAL DRIVE. DANOENONG MC, 3175. PHONE (03) 97947155 FAX (03) 9794 7635 MATERIAL The delals ond durian shown op thie DRN AH TILE CHUTE AND COMPACTOR AS raning ofe the property of oN WASTECH EXGINEERNG PTY. LTD. CKD S.F S.L GROUP — BALENCEA APARTMENT 4378002) 1 re gs en ee ten egpowsl ot [APP ——— SCALE D.N.S CAD FILE NAME REV.
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